ARFID Isn’t Picky Eating-So Stop Treating It Like It Is

A couple of weeks back I introduced how Picky Eating and ARFID are not the same. You can read more about that here. Treating someone with ARFID from a Picky Eating lens won’t move the needle. I work with many ARFID cases and all are successful in a short amount of time. You can learn more about my approach below:

1. At the initial assessment I really try to understand what triggered the fear that strengthens the avoidance and restriction. For young clients this requires a meeting with parents first. At this meeting we explore many thing such as if someone in the family is sick often, if someone has choked or experienced gagging, if their child witnessed a relative who had a tube feeding and couldn’t swallow, or if their child had their own experience with choking, vomiting, etc. Please note there are many occurrences that can trigger ARFID. It’s important to discuss in depth.
2. Once I understand what the event was that triggered ARFID I move to the education piece. Why do we vomit or choke? How do you get a virus that may cause vomiting? Once I understand the trigger I educate and assess the response and discomfort. This information provides a map on how to build from here.
3. I get a complete idea of what the “safe” foods are and assess overall intake verse needs. A hypocaloric diet negatively affects the nervous system and cognition. Increasing nutrition fuels the brain, regulates the nervous system, and helps with cognition. This leads to the first step with nutrition. Eat more of the safe foods to meet your needs.
4. Once intake is appropriate we focus on food exposures and chaining. Although I respect Ellyn Satter’s division of responsibility I think it is ineffective for ARFID cases. It may be something to introduce, if at all, later in our treatment process.
5. I create food exposures based on safe foods and responses to exposures. Parents have an emotional connection and memories which prohibit objective planning. The patient is too distressed to make any decisions on food.
6. The family or client brings in the food, we look at it from a senses standpoint to truly understand how the food looks, how it smells, and what it feels like. We take a bite and grade it A-F. If anything is a C or above we then plan how to integrate each food into the week to increase consumption and confidence.

In the last few years I’ve worked with hundreds of ARFID clients. I’ve only had one client who would not take a bite in my office. I think it’s important to note that this client was closed off to the entire idea of meeting a dietitian secondary to the ineffective and incorrect treatment they received prior. We paused food exposures and I referred to a therapist. It is very helpful for a client to be working with a therapist in conjunction with a dietitian at any time.

As for this form of treatment there are times it stalls or is ineffective. The reasons below are truthful without judgement and important to understand.

1. Lack of follow through on the parent end with integrating the food at home. Parents are fearful that their child is malnourished, however, this pattern has been in existence for some time. Once you are working with a dietitian it’s important to trust them and follow their lead without emotion.
2. A child or client may feel unsafe at home due to constant conversations about food, reactions, and more. The parent or loved one needs to provide love and support and follow the dietitians lead.
3. A lack of consequences. A sustained pattern of decreased intake leads to malnutrition and becomes a safety issue. If you can’t fuel it’s not safe to go to your game, practice, play practice, theatre or anything that requires energy.

ARFID is a newer diagnosis and there are few providers who feel comfortable with the treatment or have significant experience to draw from. It’s important to truly understand your providers experience and training to ensure positive outcomes.