I have a babbling baby who currently loves to eat nearly anything. (Watching her smear avocado onto her nine-month-old face is a genuine evening highlight.) But since I’m a contemporary parent with access to a phone, I’m also constantly in online parenting forums that claim to know what’s right around the corner for her: extreme pickiness around food. I’m constantly dreading that moment when she declares that she won’t eat broccoli — or any green vegetable at all. I’ve seen parents on Reddit and Discord write lengthy paragraphs lamenting their child’s total dependence on crackers and milk as their sole sources of nutrition.
And yet, parents battling this type of food aversion seem to be the “lucky” ones: There’s also a segment of parents dealing with an even more extreme version of food fussiness, called Avoidant/Restrictive Food Intake Disorder. According to the missives sent out onto the web, this is nuclear pickiness — like a kid insisting that they will only consume four or five (usually beige) foods.
Officially added to the DSM-IV in 2013, ARFID means severely restricting the amount and/or type of food you eat. Skeptics may say this is just ultra-pickiness, but stressed parents hotly disagree. Many say that their kids with ARFID appear to actually fear certain foods, and throw tantrums when they’re served something like pesto. Other children eat so little, they may verge on starving themselves; some may even have developmental disorders like delayed puberty because of nutritional deficiencies. Mental-health experts say that ARFID isn’t fussiness: It’s an eating disorder.
Even if you aren’t raising a child, ARFID still may be relevant to you. Reaching adulthood doesn’t mean you’ve aged out of this condition; adults can be diagnosed with it. One study of about 50,000 adults found that 4.7 percent of respondents screened positive. And these aren’t necessarily people whose childhood food anxieties have lasted a lifetime; you can also develop ARFID later in life.
Are parents of ARFID-affected kids just pushovers who need to put their feet down? Do the adults who are suffering from these aversions just need to “get over” them? And why, 10 years after being added to psychiatric nomenclature, is this “new” eating disorder still so hard to understand? To dig into the facts, we spoke with Rachel Kramer, Ph.D., a clinical psychologist at the University of California, San Francisco, to learn about how to treat people who suffer from the disorder. We also consulted Jaclyn Macchione, an occupational therapist at The Renfrew Center, an eating disorder treatment program, who explained her radical approach to treating patients of all ages.
What is ARFID?
ARFID, per the Cleveland Clinic, is “a condition that limits your food intake.” Unlike more commonly diagnosed eating disorders, “it isn’t caused by a negative self-image or a desire to change your body weight.” Instead, “fear and anxiety about food or the consequences of eating, like choking, can lead to ARFID.” Similarly, fear of vomiting, food allergies, or fear of possible GI distress can fuel the disorder.
You may look at this criteria and say it appears to be learned behavior that doesn’t constitute a huge problem; after all, the negative self-image that’s a hallmark of disorders like anorexia nervosa isn’t at play. But according to Macchione and Dr. Kramer, the severity of ARFID can lead to nutritional deficiencies, growth issues, and problems socializing (since parties and celebrations always revolve, in part, around food).
Aside from the very real physical and social ramifications of ARFID, the anxiety it creates around food can be so extreme that it becomes all-encompassing. Macchione says, “A kid [with] a peanut allergy, [could] over time start generalizing their fear.” She explains they might express concerns around eating any type of nut, anything the same color as peanuts, or even items also found in the peanut butter aisle of the grocery store.
What are the subtypes of ARFID?
According to a 2024 article in the Journal of Eating Disorders, there are three subtypes of ARFID: ARFID-low appetite, ARFID-sensory limitations, and ARFID-aversive. Here’s how these three subtypes manifest:
- ARFID-sensory limitations: “This usually develops in childhood,” says Macchione. “These are the kids that have a fear of certain textures or tastes, the way that food smells, or the way that food looks. If there are any sensory aversions going on in the child’s life, a lot of times we see them avoiding food due to the sensory characteristics of the food.”
- ARFID-aversive: “This has to do with avoiding food due to the fear of choking, the fear of vomiting, or the fear of swallowing. And a lot of times, that comes from something that happened previously — if they choked at 10 years old, then all of a sudden they have a fear of eating,” explains Macchione. “The other one that we see is medical symptoms that result in ARFID. I see a lot of people who have food allergies, GI complications, and people with Crohn’s disease — they’ve learned over time that food can be harmful. They don’t want to feel distress and discomfort.”
- ARFID-low appetite: “Lack of awareness happens when it doesn’t come naturally for a person to eat,” Macchione continues. “They could go the whole day without eating and not even be aware that they didn’t eat, until somebody asks. I see this a lot with our neurodivergent population, like kids on the autism spectrum or children with ADHD.”
Keep in mind that it’s possible to experience more than one subtype, according to Macchione.
Can adults have ARFID?
A lot of the online ARFID discourse revolves around kids and parenting, but you can be diagnosed with with condition at any age — again, ARFID may affect up to 5 percent of the adult population. Dr. Kramer mentions that age truly isn’t a barrier when it comes to highly restricted eating: “I would imagine that there are senior citizens who are dealing with ARFID and might not have had support or treatment to be able to expand [their diets].”
“I’ve worked with [adults] who’ve experienced pain related to an illness that has then prompted them to have anxiety about eating,” Dr. Kramer continues. “If it’s really getting in the way and it’s above and beyond what we might typically expect, then that would fit the criteria for ARFID.”
Macchione gives a similar example: “Say [an adult] just realized they had a food allergy at the age of 20 — [ARFID-aversive] can occur then.” After all, you can develop an allergy or GI issues in adulthood. The same goes for a hazardous choking event, which could happen at any point in one’s lifetime.
How is ARFID treated?
If someone’s hungry enough, won’t they just eventually…eat?
Macchione clarifies that that’s not the case: “You can grow out of picky eating, but you can’t grow out of ARFID.” So treatment is required, just like any other eating disorder — and if the patient is a child, it’s not as simple as sending your kid off to therapy solo. As Dr. Kramer explains, “A lot of the treatments that have been developed incorporate families. Not [eating] can have a really big impact on the [whole] family.”
Dr. Kramer says there are a few common treatments for children, including CBT-AR: This version of cognitive behavioral therapy emphasizes the struggles that patients with ARFID experience, and aims to help through talk therapy.
“It also takes an approach of parents being more in charge of choosing meals or choosing meal times and helping their teen or child through each meal,” Dr. Kramer says. What does that help look like? “Sometimes it’s using distraction or different techniques. And it incorporates some of what we use for anorexia, which is family-based treatment.”
Another treatment developed for younger kids, called Feeling and Body Investigators, was adapted for ARFID: “It creates characters for every single type of body sensation to help kids become more comfortable with body sensations.” (Think cartoonish illustrations of characters like Harold the Hunger Pain and Victor Vomit.)
Macchione has designed an entire ARFID-specific recovery program at Renfrew that emphasizes exposure to fear foods: “I always say, ‘I can’t talk you into not being fearful about food anymore.’ …We do exposure therapy, but we do it in a very systematic way. We start off with the least distressing foods, and then we work our way up to the high distressing foods. This has to occur over a period of time to build enough emotional tolerance to anxiety, disgust, and fear.”
“What makes our program very different from others in the country is that I wanted it to feel like a separate program,” she continues. “So those coming in with ARFID have their own menus distinct from other patients — they’re in a different building from the other patients. It’s very specialized, very separate, and I think that’s why we see such success. Because ARFID needs to be treated differently.”
“I’ve treated over 300 people with ARFID over the years,” she adds. “Recovery doesn’t look the same for everybody. However, we have such a good handle on ARFID treatment and interventions that they’re really successful, and we see progress very fast.” With growing recognition of ARFID as a valid and serious eating disorder, tailored treatments are proving that recovery is essential — and possible.
