ARFID has nothing to do with fussy eaters, it's when a child has a fear of food

ARFID is a real condition where babies and children avoid, restrict or refuse food, often due to painful associations, says Áilín Quinlan

HE’S now a muscular 6 ft 3in athlete who successfully competes in a variety of sports, but for years my son didn’t like eating.

As a baby, Zach, now aged 20, had a bout of gastroenteritis.

It took hours for him to get a single bottle down. Even when he was a toddler, meal times were difficult.

He had no interest in food or in eating and eventually ended up sitting on the desk of a paediatrician, who mused aloud that my small son was probably “pushing Mummy’s buttons”.

However, after years of being labelled a ‘picky eater’, the problem slowly receded; Zach gradually started to eat without prolonged argument.

Now, looking back, I wonder if all those years ago, he had a very mild case of what has only relatively recently been officially categorised. 

Avoidant and Restrictive Food Intake Disorder or ARFID, a condition which was only added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s reference manual, in 2013.

ARFID has nothing to do with fussy eaters, it's when a child has a fear of food

Certainly, parents get stressed when children fuss with their food, and most children go through an enjoyable phase or two of pushing their parents’ buttons.

However, says Dublin-based paediatric dietitian Ruth Charles, a lot of children who have ARFID may be written off as ‘picky eaters,’ ‘fussy eaters,’ or as just plain ‘bold’.

ARFID, she explains, is an eating or feeding disturbance where those affected either don’t eat enough or show little interest in feeding, only accept a limited diet because of sensory issues and refuse food — primarily because of a previous bad experience with eating or food.

The condition, she adds, will usually interfere significantly with “normal” social and emotional development or functioning — for example, a child may not even want to attend birthday parties or family, school, or sporting events where food they don’t like may be served.

It is usually rooted in a negative feeding experience she explains — for example, the effect of being really sick and being made to eat by a worried parent she says.

ARFID has nothing to do with fussy eaters, it's when a child has a fear of food

ARFID can also be linked to experiences with bad colic or reflux. In situations where a sick child doesn’t want to be fed but is pushed to eat by anxious parents, the feeding can backfire, resulting in a negative feeding experience, the effects of which can be lasting.

“It really comes back to an experience which equals discomfort or/and pain for the child and which is associated with eating. Then the child doesn’t want to do it anymore,” says Charles.

“The longer it goes on the more chance there is of it becoming a sensory issue.”

An ARFID child may self-limit his or her eating to a few foods they perceive to be “easy” or “safe” such as yoghurt, or to drinking milk from the bottle, she explains. 

“I call this a “beige” diet where the food is the same colour, for example, bread, crackers, rice, milk, yoghurt, there is no colour, no surprises.”

Needless to say, parents can become very stressed over this kind of behaviour. 

After all, as Charles points out, “the book” tells parents that a child should be eating certain things by the time he or she is two — and if you have a child who will only drink from the bottle or eat crackers it can be very upsetting.

Parents will try everything to encourage an ARFID child to have a healthy diet, from creating ‘funny faces’ with food on a child’s plate to cooking with them, bringing them shopping and even letting them pick out the food they would like to eat.

ARFID has nothing to do with fussy eaters, it's when a child has a fear of food

In some cases, the condition can be more extreme. 

Charles knows of children who will have a “meltdown” if a food other than that on their very limited list of consumables appears on their plate — for example, a slice of cheese on a cracker.

“These children do get hungry, but they don’t know that they are actually hungry or that by eating food the hunger will go away.”

Such children graze on perceived ‘safe’ foods such as toast or crackers.

“These children are normally quite healthy and look normal — they are growing because they are getting enough calories, because they are constantly grazing,” she says.

However, despite the received wisdom that children will ‘grow out of it’ or ‘eat when he gets hungry’, this usually doesn’t happen.

“That is because the cause of it is still there. The legacy is still there — the vomiting or the pain that is associated with eating.”

This condition is essentially a child’s visceral refusal from within a child to eat food.

“Tackling that is a major problem. First of all, it’s about recognising that it is a real condition and that these are children who insist on a bland diet.”

ARFID has nothing to do with fussy eaters, it's when a child has a fear of food

Next, she says, their way of eating is significantly interfering with their lives — for example not going to school outings, or birthday parties because they don’t want to go anywhere that might put them in a situation where they feel they are supposed to eat food they don’t want.

“I see so many children who are demonised as bold or called a fussy eater and told they are pushing mum’s buttons — but what is happening is these children are afraid of food; afraid of something bad happening if they eat.”

“It has a major effect on their lives and that’s why ARFI is so important,” she says, emphasising that there’s a big difference between the child who won’t eat cabbage but will eat broccoli or carrots and the child whose lifestyle is severely compromised by how they eat.

“They are growing and putting on weight but when you dig deeper, you’ll find, for example, that they will get anxious around social events which involve food.”

For parents, who often feel they are not nurturing their child through food as normal, the guilt and stress can be significant, Charles says.

The condition, she says, requires a multi-disciplinary approach ideally involving a dietitian, speech therapist, occupational therapist and psychologist who are skilled and knowledgeable about the condition.

Top tips

* Go with your gut. If you feel your child fits these criteria, trust yourself. You’re more than likely not imagining it, says paediatric dietitian Ruth Charles.

* Recognise that your child is not simply being ‘bold’. They’re experiencing a visceral inability to eat a normal diet.

* Understand that avoidant/ restrictive food intake disorder is a relatively new diagnosis which is based on the effect a child’s poor eating habits has on its lifestyle and general functioning, and that general awareness of the condition is still relatively poor.

* Discuss the situation with your GP or public health nurse and access the primary care team and healthcare professionals in your community such as a speech therapist, occupational therapist or dietitian.

* Understand that this is a condition which will take time and the help of skilled professionals and that dealing with it, says Charles, will be a matter of taking baby steps.

* Educate yourself — see: www.aboutkidshealth.ca 


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