Family Meals Focus
The Ellyn Satter Institute Newsletter
ARFID, feeding dynamics, and sDOR
by Ellyn Satter, MS, MSSW, Jennifer Harris, RDN, LD, CEDRD-S, Keira Oseroff, MSW, LCSW, CEDS
For a PDF of this newsletter, click here
Parents who have struggled long term with their child around eating are often relieved when their child is diagnosed with ARFID. It means to them that after years of reassurance, brush-offs, partial solutions, and ineffective advice, their concerns are being taken seriously. An ARFID diagnosis positions parents to get access to care and supports third-party payment for treatment. ARFID problems are far more serious and entrenched than the ordinary food refusal, choosiness, and over- and undereating displayed by up to half of children.1 In practice, the ARFID diagnosis is generally reserved for the child who has a growth deficiency, relies on oral or tube-fed meal replacements, and/or whose restrictive eating has interfered with psychosocial functioning. What, then, is ARFID?
What is ARFID?
Avoidant/Restrictive Food Intake Disorder (ARFID) is the American Psychiatric Association Diagnostic and Statistical Manual 5 (DSM-5) diagnosis of feeding disorder of infancy or early childhood.2 In the words of DSM-5, ARFID is 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 weight faltering, significant nutritional deficiency, dependence on enteral feeding or oral supplements, and/or marked interference with psychosocial functioning.
fdSatter, sDOR, and ARFID
The Satter Division of Responsibility in Feeding (sDOR) is endorsed as best practice in feeding by prominent child pediatrics and nutrition agencies such as the American Academy of Pediatrics and the Academy of Nutrition and Dietetics. Building on that endorsement, a Satter Feeding Dynamics Model (fdSatter)-consistent team approach incorporating sDOR3 is recommended as best practice in addressing ARFID. fdSatter and sDOR are family-focused and shape a positive feeding relationship. From the fdSatter perspective, the ARFID diagnosis, the same as any other feeding problem, exists not just in the child but in the whole parent-child feeding relationship.4 ARFID presents as stress-ridden and long-standing struggles around feeding, resistant to multiple efforts at resolution, and likely accompanied by growth distortion.
Professionals trained in the fdSatter-based Ellyn Satter Institute Feeding with Love and Good Sense VISION workshop begin by doing a complete workup: A detailed assessment of medical, nutritional, developmental, psychosocial, and feeding-dynamics issues.5 This comprehensive assessment reviews the child’s clinical records from birth, replots growth, reviews the child’s developmental and feeding history, assesses the child’s food intake and nutritional status, examines the psychosocial context of feeding, and observes feeding dynamics. Based on that workup and within the context of a treatment team, ESI-trained professionals plan and carry out sDOR-grounded treatment integrated with skillful attention to complicating medical, nutritional, and oral-motor issues. That pressure-free feeding supports children in bringing themselves along with respect to eating to the best of their abilities.
While sDOR forms the core of fdSatter-consistent ARFID treatment, parents can’t simply be advised to follow sDOR.
sDOR can’t stand alone
While sDOR forms the core of fdSatter-consistent ARFID treatment, parents can’t simply be advised to follow sDOR. Feeding struggles are complex, deep-rooted, and long-standing, and parents are frightened for their child’s well-being: They need to be able to trust the intervention. The assessment and treatment-planning process identify the components of the problem and allow parents to feel that they, their child, and their situation are fully understood. Without a detailed workup, advice to follow sDOR comes across as just one more of the many partial and piecemeal bits of instruction they have been given over the years. Parents need expert help to tailor the nuances of the what, when, and where of feeding to their own and their child’s needs. Once sDOR is defined in individualized and achievable ways, parents need support for taking and maintaining the leap of faith necessary to let their child do the how much and whether of eating at the same time as they recognize the child’s ways of gradually learning to eat.5
Understanding empowers change—and trust
fdSatter-trained professionals work with the parents of the child diagnosed with ARFID, not the child directly, and see the child as being innately competent with eating. This treatment approach identifies and corrects past and present feeding dynamics that interferes with the child’s Eating Competence, helps parents establish what- when- and where-adjusted sDOR, and helps parents hold steady with feeding while children develop increased capabilities with eating. This is in contrast to approaches that work directly with the child diagnosed with ARFID and that include parents only from the point of view of applying the treatment at home.6 These approaches characterize the child’s avoidant/restrictive food attitudes and behavior as based on a deficit in the child: as having a sensory processing disorder or being so eating-averse that they will go hungry rather than eat food beyond their comfort level. Interventions focus on getting the child to eat. Children may be offered special foods or have meals catered to them. Children are rewarded, enticed, or pressured to mouth, touch, lick, and/or smell food using selective attention, praise, games, cheering, tokens, and elaborate modeling. Children may be maneuvered into eating rejected food by blending it with preferred food or gradually modifying the taste and texture of preferred food. Extreme forcing methods include punishing children’s not-eating by withholding privileges or attention, not letting children refuse food, or physically compelling them to eat. While pressuring, enticing, encouraging, and forcing tactics may increase the child’s food intake in the short term, they are not sustainable. Parents typically have too little time and energy and too much empathy with the child to keep the intervention going and the feeding struggles re-emerge.
The course of treatment
Working with an AFRID-diagnosed family to establish and maintain a positive feeding relationship takes considerable skill, perseverance, and flexibility. Once sDOR is in place, the atmosphere at family meals quickly takes a positive turn and sets the stage for the resolution of ARFID, which can take years. Over that long term, parents have to remain consistent with sDOR and withstand outside interference as well as their own entirely natural, but counterproductive, impulses to speed the process along. Particularly cautious children and those who have pronounced oral-motor sensitivity take longer to bring themselves along with food acceptance and food regulation. Depending on their degree of involvement, children with neurological and developmental challenges take longer still and, indeed, may not be able to fully support themselves by eating. Those parents and children can still have a positive feeding relationship. Children can eat at family mealtime until it is no longer enjoyable, then satisfy the rest of their nutritional needs via supplemental feeding.
- Silverman AH, Tarbell SE. Feeding and vomiting problems in pediatric populations. In: Roberts MC, Steele RC, eds. Handbook of Pediatric Psychology. Guilford Publications; 2017:402-416:chap 31.
- American Psychiatric Association. Feeding and Eating Disorders. DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013:329-354.
- Satter E. The Satter Feeding Dynamics Model (fdSatter) and the Satter Division of Responsibility in Feeding (sDOR): A narrative review. TBD. 2022;
- Davies WH, Satter E, Berlin KS, et al. Reconceptualizing feeding and feeding disorders in interpersonal context: the case for a relational disorder. J Fam Psychol. 2006;20:409-417.
- Satter E. Appendix E, Assessment of Feeding/Growth Problems. Your Child’s Weight: Helping Without Harming. Kelcy Press; 2005:396-402.
- Satter E. Intervening with pediatric feeding disorders. Ellyn Satter Institute. Accessed March 19, 2022, 2022. https://www.ellynsatterinstitute.org/how-to-feed/intervening-with-pediatric-feeding-disorders/
ARFID: American Psychiatric Association DSM 5 Diagnostic and Statistical Manual.
Avoidant/Restrictive Food Intake Disorder replaces and extends the DSM-IV diagnosis of feeding disorder of infancy or early childhood. ARFID is 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.
In some individuals, food avoidance or restriction may be based on the sensory characteristics or qualities of food, such as extreme sensitivity to appearance, color, smell, texture, temperature, or taste. Such behavior has been described as ‘restrictive eating,’ ‘selective eating,’ ‘choosy eating,’ ‘perseverant eating,’ ‘chronic food refusal,’ and ‘food neophobia’ and may manifest as refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others.
Intervening with Pediatric Feeding Disorders
More about understanding established feeding problems from the perspective of the Satter Feeding Dynamics Model.
Related issues of Family Meals Focus
- Does the division of responsibility in feeding work in clinical care?
- Eating competence: Food acceptance
- Picky eating: Born or made?
- Picky eating in adults: How to help
- Toddler feeding: A series of unfortunate events
- Toddler feeding: the child who won’t eat table food
- Toddler feeding: What’s the big deal?
Address food refusal wisely and well
- Avoid pressure
- Family-friendly feeding tips
- Follow Satter’s Division of Responsibility in Feeding(sDOR)
- How children become competent eaters
- How to become eating competent
- The adult picky eater
- The picky eater