arfid

Who Helps A Child With ARFID?

Parenting /

As the saying goes, “it takes a village”. If you are looking for more support to help yourself or your child treat ARFID, you likely already deeply resonate with this saying. Luckily, the research is growing and the awareness is improving and spreading in the eating disorder field to help diagnose ARFID with more ease and specific criteria. The next order of business is creating your “village”.  Curating a specialized multidisciplinary team is the most tried and true approach to eating disorder treatment. At the most basic level, a doctor (preferably a child and adolescent medicine specialist for the kiddos), a registered dietitian (heads up to ensure actual RD credentials, not just a nutritionist label) with a Certified Eating Disorder Specialist credential indicated by “CEDS”, and a therapist who specializes in eating or feeding disorders. For more complex individual cases, a speech language pathologist and feeding specialist are essential components. When the whole family and team work together to change meal time behaviors, success will follow.  What does an RD do to treat ARFID?  In one on one sessions or parent joined sessions, we will educate you on healthy eating and addressing food fears one step at a time, to empower you to face these fears and live a full life that YOU control, not ARFID. We will teach you and/or your kiddo to move up the ladder and include all food groups gradually, moving up the steps to eating, without meltdowns and shuts downs. Treatment includes developing pre and post mealtime coping strategies, meal time structures and psychoeducation, as well as hands-on regulation tools to help quiet the chaos and create opportunity for change. In addition, the dietitian’s role may look like exposure therapy sessions, creating family meal calendars, meal supports, family-based interventions, cooking sessions, CBT techniques amongst other modalities (i.e. SOS Approach to Feeding, DBT, RO-DBT), and play based sensory exposures and integration. Visit our previous blog on How to Use a Food Hierarchy in ARFID for a more in depth look on what some of your nutrition sessions may look like. For children and adolescents, doctors will monitor labs, growth charts, and vitals ensure your kiddo is hitting their targets and getting back on their growth trajectory and prevent nutrient deficiencies. Additionally, doctors may prescribe medications to increase appetite or treat underlying/cooccurring anxiety. The therapist on the team will also troubleshoot this frequented component in sessions. OCD, ADHD, and sensory processing disorders and sensitivities are often co-ccuring in individuals with ARFID, therefore a therapist and dietitian will often use Cognitive Based Therapy (CBT) skills to help foster the safe connection between mind and body, the thoughts, feelings and behaviors. Navigating ARFID treatment can be tough and overwhelming, but we are here for you. Reach out to us and we would be happy to discuss how we can support you and connect you with experts in the space.

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Is it ARFID, Anorexia, or Both?

Lifestyle /

Eating disorders can be complex and multifaceted, making accurate diagnosis and treatment crucial. Two disorders that often cause confusion are Avoidant/Restrictive Food Intake Disorder (ARFID) and Anorexia Nervosa. Both involve restrictive eating, but they manifest differently and require distinct approaches for effective management.  At the same time, both disorders are rooted in disturbance in sensory processing.  In this post, we delve into the overlap between ARFID and anorexia through the lens of a sensory processing disorder.  Understanding ARFID and Anorexia Nervosa ARFID is a relatively newer diagnosis that involves a significant reduction in food intake due to various factors, including sensory sensitivities, a lack of interest in food, or a fear of negative consequences of eating, such as choking or vomiting. Individuals with ARFID may experience extreme picky eating, aversions to specific textures or colors of food, or a general lack of appetite. Unlike anorexia, ARFID does not necessarily involve a desire to lose weight or a distorted body image.1  Because ARFID is still a newer diagnosis, it often leads to misdiagnosis or delays in diagnosis.  Anorexia nervosa, on the other hand, is characterized by an intense fear of gaining weight and a distorted body image, which leads to severe food restriction. Individuals with anorexia often see themselves as overweight despite being underweight, and their eating behaviors are driven by a desire for weight loss and an obsession with body shape and size.2  Key Differences Between ARFID and Anorexia Nervosa Motivation Behind Food Restriction: ARFID: The restriction is often due to sensory sensitivities, a lack of interest in food, or past negative experiences related to eating. There is typically no desire for weight loss or a preoccupation with body image. Anorexia Nervosa: The restriction is driven by an intense fear of weight gain and a distorted perception of body image. The primary motivation is often to lose weight and maintain a low body weight. Body Image and Self-Perception: ARFID: Individuals with ARFID generally do not have a distorted body image. Their concerns are more about the sensory aspects of food or past experiences rather than their body weight or shape. Anorexia Nervosa: Body image distortion is a core feature. Individuals may see themselves as overweight even when they are dangerously underweight and may have an obsession with being thin. Eating Behaviors: ARFID: Eating behaviors in ARFID can include extreme selectivity in food choices, aversion to certain textures or colors, or avoidance of food due to fear of adverse consequences, such as choking or gastrointestinal discomfort. Anorexia Nervosa: Behaviors often include strict calorie counting, excessive exercise, and rituals around eating. Food intake is meticulously controlled with the goal of losing weight. Physical Health: ARFID: Physical consequences can include malnutrition and weight loss, but the primary issue is not necessarily driven by a desire for thinness. Growth delays and nutrient deficiencies are common, especially in children and adolescents. Anorexia Nervosa: Severe malnutrition is a result of extreme caloric restriction and can lead to a host of medical complications including cardiac issues, osteoporosis, and organ failure due to the drive for thinness. Co-occurrence of ARFID and Anorexia Overlap between ARFID and anorexia is frequently seen when individuals with ARFID also develop symptoms and features of anorexia. In addition to food sensitivities and aversions, they may also have concerns about body weight and shape, preference for less calorically dense foods, negative body image or body dysmorphia, and fear of weight gain.  There is increasing research that anorexia is also a disorder that involves sensory processing disturbances. These individuals may display a lack of interoceptive awareness and inability to feel hunger and fullness cues, which have an influence on how they process taste and sensations.3  ARFID is common in neurodivergent individuals.  Because anorexia is based in sensory disturbances as well, it is imperative to understand how this overlap may manifest for people with ADHD or autism.  For example, while fear of weight gain is a common characteristic of anorexia, it is not an experience shared by all with the disorder.  For a neurodivergent individual, their eating disorder symptoms may arise from a need for safety and control where they may feel challenged with change and lack of a routine.   Additionally, those with co-occurring ARFID and anorexia may experience nutritional deficiencies, gastrointestinal discomfort, challenging eating in social settings, fear of judgement from others, and mistrust and disassociation from their bodies.4  Treatment of Co-occurring ARFID and Anorexia Treatment of these overlapping eating disorders requires medical oversight, nutritional rehabilitation, as well as work toward establishing trust and safety in the body.  In collaboration with an eating disorder therapist and registered dietitian, clients may work through food exposures, increasing their food variety, and re-establishing interoceptive awareness.   Understanding whether one is dealing with ARFID, anorexia nervosa, or a combination of both is crucial for effective intervention and recovery. Treating clients from a sensory processing disorder perspective can be helpful in identifying when overlapping ARFID and anorexia are present.  Both disorders require compassionate, creative, and individualized care and support from a team of professionals including an eating disorder registered dietitian, therapist, doctor, and psychiatrist.  At Laura Cipullo Whole Nutrition Services, our team of dietitians is here to support.    Zimmerman J, Fisher M. Avoidant/Restrictive Food Intake Disorder (ARFID). Curr Probl Pediatr Adolesc Health Care. 2017 Apr;47(4):95-103. doi: 10.1016/j.cppeds.2017.02.005. PMID: 28532967. Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U. Anorexia nervosa: aetiology, assessment, and treatment. Lancet Psychiatry. 2015 Dec;2(12):1099-111. doi: 10.1016/S2215-0366(15)00356-9. Epub 2015 Oct 27. PMID: 26514083. Cobbaert L, Hay P, Mitchell PB, Roza SJ, Perkes I. Sensory processing across eating disorders: A systematic review and meta-analysis of self-report inventories. Int J Eat Disord. 2024 Jul;57(7):1465-1488. doi: 10.1002/eat.24184. Epub 2024 Mar 21. PMID: 38511825. Becker KR, Breithaupt L, Lawson EA, Eddy KT, Thomas JJ. Co-occurrence of Avoidant/Restrictive Food Intake Disorder and Traditional Eating Psychopathology. J Am Acad Child Adolesc Psychiatry. 2020 Feb;59(2):209-212. doi: 10.1016/j.jaac.2019.09.037. Epub 2019 Nov 26. PMID: 31783098; PMCID: PMC7380203. https://neurodivergentinsights.com/misdiagnosis-monday/anorexia-and-arfid?format=amp  

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How to Use A Food Hierarchy in Treating ARFID

Lifestyle, Parenting /

Most often in our practice, we treat our clients who present with an ARFID diagnosis with Cognitive-Behavioral Therapy for ARFID, also known as CBT-AR1 (as well as Laura and Paige’s sprinkle of knowledge and training from the SOS Approach to Feeding).    ARFID is defined by the DSM-5 Criteria2 as: An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: Significant weight loss (or failure to achieve expected weight gain or faltering growth in children) Significant nutritional deficiency. Dependence on enteral feeding or oral nutritional supplements. Marked interference with psychosocial functioning. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another mental disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.  The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. Avoidance is Only a Temporary Solution  Avoidance of certain food groups, textures, flavors, smells, etc. in an individual with ARFID only is a temporary solution to their anxiety. The longer one avoids the heightened the anxiety, the more coping strategies needed to regulate. It is important to understand that an individual with ARFID is not just being difficult, picky or stubborn. This is a true biological wiring in which requires unlearning their learned adaptive behaviors. This individual may be using adaptive behaviors such as small bites, chewing for much longer than necessary, only eating “safe” foods in an exactly specific way, or even not eating at all as a way to cope with their discomfort or lack of sensory regulation. In order to interrupt such avoidant behaviors, we must “test the hypothesis”, in other words, do the scary thing to see that the negative prediction is not always the factual outcome. The most tried and true way to tackle this in treatment is exposure therapy. The best way to overcome the fear is to work on exposures to such fears in a planned and systematic way. We do this is by creating a food exposure hierarchy. Within the first few sessions with our clients, we will assist them and their families in creating an exposure hierarchy, an plan out one at a time, facing these fears and aversions.  Creating an Exposure Hierarchy  To create your own exposure hierarchy, you will rank you food fears from least anxiety provoking to most anxiety provoking using a scale from 1-100, called subject units of distress. Pending the age of the client we may narrow this range such as 1-10, or using colors. It is most important for the individual to create a ranking system that resonates with them and they can understand. We recommend moving at the pace the individual is ready for, starting with lower ranked, easier, foods and progressing to more challenging ones with increasing trust and comfortability. Download our template below and give it a try. Working with a registered dietitian and multidisciplinary team to work through the thoughts, feelings and behaviors that come up around these food fears as you try moving up this ladder is the best way to make sustainable and meaningful progress.  

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Four Types of ARFID

Lifestyle /

ARFID, also known as Avoidant/Restrictive Food Intake Disorder, is a newly recognized eating disorder characterized by individuals having an extreme aversion to certain foods or food groups, leading to limited or restrictive food intake1,2.  This disorder can pose significant challenges for those struggling with ARFID, as it can greatly impact their overall health3.  Some individuals may have strong aversions to certain foods due to sensory issues or past negative experiences; however, individuals with ARFID experience these aversions to such an extreme degree that it impairs their ability to maintain a balanced diet.  This can result in weight loss, nutrient deficiencies, malnutrition, and other health complications2,3,4.  In contrast to other eating disorders like anorexia nervosa or bulimia nervosa, ARFID does not involve body image concerns1,2, rather, a genuine fear or anxiety around certain foods, which can make mealtimes a source of stress and discomfort.  Researchers have identified different subtypes of ARFID, including sensory-based and fear-based restrictions, with some individuals experiencing a mix of both5.  Each subtype presents its own set of challenges and behavioral patterns and may require a different approach to diagnosis and treatment. Avoidant ARFID What sets eating apart from other activities is that it engages all eight senses: sight, smell, taste, touch, hearing, vestibular (sense of balance), proprioception (sense of body position), and interoception (internal awareness)6.  Individuals with the avoidant type of ARFID have a heightened sensitivity to such aspects and may find certain foods to be intolerable due to these sensory sensitivities5.  For example, a person with the avoidant type of ARFID may refuse to eat foods with a certain texture, like mushy or crunchy foods, because they find them unpleasant to eat.  Restrictive ARFID Have you ever become so engrossed in a task that you forgot to eat or even missed a meal?  This phenomenon is not uncommon among individuals who are highly focused on their work or activities; however, for those with the restrictive type of ARFID, the reasons behind missing meals may be quite different. Specifically, individuals with the restrictive type of ARFID may not eat due to poor interoception and/or lack of interest in eating5.  Interoception refers to the ability to perceive internal bodily sensations, such as hunger and fullness cues6.  Difficulty in recognizing these cues can lead to unintentionally skipping meals.  Aversive ARFID Negative experiences with certain foods can have a lasting impact on our perception and future willingness to consume them.  For example, if someone gets food poisoning from eating sushi at a restaurant, they may develop a fear or disgust towards sushi in general. This understandable reaction may serve as a defense mechanism to prevent future illness or discomfort and, for most people, does not significantly affect their overall diet.  They may simply avoid the food that caused them harm and continue to eat many other foods.  Similarly, with the aversive type of ARFID, food avoidance may be due to negative experiences or fear of choking, vomiting, food poisoning, or other adverse effects5; however, these individuals may avoid a variety of foods, not just those that have directly harmed them.  If left untreated, it can lead to nutritional deficiencies and other health problems2,3. Mixed ARFID Finally, mixed ARFID combines both sensory-based and fear-based restrictions: that is, individuals may avoid certain foods due to their texture, taste, or smell, as well as fear of choking or vomiting5.  Research suggests that individuals with ARFID may experience each subtype to varying degrees, meaning one may be predominant7.  This dual impact can make it even more difficult to meet nutritional needs and maintain a healthy weight.   Key Takeaways In conclusion, while classifying ARFID subtypes can be useful for diagnostic and treatment purposes, it is important to consider the unique needs and challenges of each ARFID patient.  In doing so, clinicians can provide more effective and compassionate treatment that addresses the root causes of the disorder and supports long-term recovery.     References National Eating Disorders Association. Avoidant Restrictive Food Intake Disorder. Nationaleatingdisorders.org. Published 2023. Accessed July 1, 2024. https://www.nationaleatingdisorders.org  Attia E, Walsh BT. Avoidant/Restrictive Food Intake Disorder (ARFID) – Avoidant/Restrictive Food Intake Disorder (ARFID). Merck Manual Professional Edition. Published July 2022. Accessed July 1, 2024. https://www.merckmanuals.com/professional/psychiatric-disorders/eating-disorders/avoidant-restrictive-food-intake-disorder-arfid?query=avoidant/restrictive%20food%20intake%20disorder  Nitsch A. ARFID (Avoidant Restrictive Food Intake Disorder) | Symptoms & Treatment. ACUTE. Published May 26, 2022. Accessed July 1, 2024. https://www.acute.org/blog/avoidant-restrictive-food-intake-disorder-arfid-signs-symptoms-treatment  ARFID Eating Disorder: Comprehensive ARFID Treatment. The Emily Program. Accessed July 1, 2024. https://emilyprogram.com/eating-disorders-we-treat/avoidant-restrictive-food-intake-disorder/ Douglas S. The Link between ARFID and Neurodiversity. dietwise.net.au. Published May 29, 2024. Accessed July 1, 2024. https://dietwise.net.au/2024/05/29/the-link-between-arfid-and-neurodiversity/#:~:text=Mixed%3A%20characterized%20by%20having%20two Saunders (Bulman) M. The Sensory Experience of Eating: Part 1. The Healthy Eating Clinic. Published February 8, 2023. Accessed July 1, 2024. https://healthyeatingclinic.com.au/the-sensory-experience-of-eating-part-1/  Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT. Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Current Psychiatry Reports. 2017;19(8). doi:https://doi.org/10.1007/s11920-017-0795-5 

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