Family Meals Focus
The Ellyn Satter Institute Newsletter
ARFID: What is it? What does it have to do with feeding dynamics and eating competence?
by Ellyn Satter, MS, MSSW, Dietitian and Family Therapist
Most problems with eating and feeding are not psychiatric disorders. They are problems, and, as such, can be addressed by education or brief informed treatment. The ARFID diagnosis, Avoidant/Restrictive Food Intake Disorder pathologizes picky eating and implies a cure that is unlikely to be delivered. This psychiatric diagnosis puts intervention in the hands of mental health professionals, who are unlikely to be familiar with research and optimum practice around feeding and eating.
Detect and remove the pressure; don’t diagnose
A mother writes: What are your thoughts on ARFID? Although my six-year-old son is a much happier kid since we have been following the Satter Division of Responsibility in feeding and the pressure is off, he is still resistant. He has compared eating to being in a dungeon with a wall of spikes closing on him and diving in a pool of sharks. I don’t want him to be stuck with this eating problem. I just wonder if I am doing enough or what kind of approach or treatment do you think is suitable for ARFID?
Your son’s sharks and spikes describe his experience of being pressured to eat. If he is happier, you have come a long way. If he stays happier, he will move himself along with respect to learning to eat a greater variety of food. But keep in mind this critical point: his being “resistant” means that something is going on with feeding that he has to resist. Namely, pressure. The solution is to detect and remove the pressure, not to apply a diagnosis. Diagnosing is likely to increase the pressure, exacerbate his negative eating attitudes and behaviors about eating, and worsen his food consumption. His creative and colorful language aside, his being skeptical of new food and taking a while to learn to eat it is more than likely to be an extreme of normal. That being the case, you can manage it with skillful application of sDOR. Resorting to a disease label will call for some as-yet undefined disease treatment. That will take his eating out of the realm of your feeding relationship and put it in the hands of a professional who may or may not know as much as you do about feeding.
Concerns raised by ARFID
As you know, ARFID is a diagnosis established by the American Psychiatric Association1 (see sidebar). As demonstrated by our story, the public hears about this diagnosis, which uses common language to describe feeding problems, and sees the diagnosis as offering a solution to those problems. The media heightens concern with horror stories about children who only eat chicken nuggets or peanut butter sandwiches or who have grown up to be adults who only eat French fires or waffles. How are we to interpret and work with this diagnosis?
Diagnosing may catastrophize
Most problems with eating and feeding are not psychiatric disorders. They are problems, and, as such, they can be addressed by education or brief intervention conducted knowledgeably.
Diagnosing variants of children’s normal as being problematic creates a non-existent problem. Seventy-five percent of mothers interpret their child’s initial refusal of new foods as being picky eating. All children are skeptical about unfamiliar food. Some children are temperamentally inclined to be particularly cautious in general and especially skeptical about unfamiliar food. Some children have greater-than-usual sensitivity to tastes and textures and are not particularly enthusiastic about eating. However, provided parents follow the Satter Division of Responsibility in Feeding, which allows repeated neutral exposure to unfamiliar food, even those sensitive, cautious, unenthusiastic children gradually learn to eat the food their parents eat. Unfortunately, today’s parents have their own struggles with eating therefore have difficulty giving their children opportunities to learn. More than half of adults test low in Eating Competence,2–5, 6 meaning they feel negative about eating, are unreliable about feeding themselves, hesitate to let themselves eat food they enjoy, and are unlikely to depend on their hunger and fullness in guiding how much to eat.7 Almost all parents of preschoolers make feeding errors that exacerbate their children’s challenges with eating. Parents may limit menus to foods their children readily accept, then bribe and pressure them to eat.8 Despite the national hysteria about child overweight, over 90% of parents say they don’t believe their children’s indications of fullness and encourage them to eat more.8,9 Such pressure doesn’t work: pressured children eat less well and behave badly at mealtime.10
Inclusion in DSM implies that picky eating is a psychiatric disorder
Most feeding problems are not psychiatric disorders. They are problems, and as such, they can be addressed by education or brief intervention based on the Satter Division of Responsibility in Feeding. Such problems only qualify for a psychiatric diagnosis when there is “marked interference with psychosocial functioning” (optional in the AAP definition). For any feeding malady to be a psychiatric disorder, a significant distortion in feeding has to be precipitated and/or exacerbated by and interactive with underlying psychosocial distortion. Painful as it is, the malady serves the family in some way. For the parents of children with feeding disorders, the struggle around feeding distracts from other, seemingly insoluble problems.
DSM doesn’t consider the feeding literature
The DSM states that ARFID-related problems “most commonly develop in infancy or early childhood and may persist in adulthood.” It is certainly true that feeding errors in the early years create feeding problems that are exacerbated by later common fixes. However, the DSM review shows no evidence of the rich feeding literature which outlines the detail of distorted parent/child feeding interactions that precipitate and/or fail to extinguish feeding problems.
DSM considers disorders in isolation
Child psychosocial issues are always part of established, problematic relationships with parents/primary care providers. Severe feeding problems must be considered in that context, and in the context of the child’s medical and developmental history.11 Affected adults carry internalized distortions from their own early feeding relationships. The parent-child feeding relationship is paramount, even when children contribute to “food intake disorders” by being irritable, having medical and/or oral-motor problems, developing atypically, or showing extreme food regulation patterns (e.g. don’t eat much or eat a great deal).
DSM diagnosis implies cures that may or may not be delivered
Certainly, people need help with their feeding and eating. However, that help must be in proportion to the problem at hand, and it must be provided by people who truly understand eating and feeding. As a mental health professional myself, I have observed that, the same as the authors of DSM 5, mental health professionals are generally not familiar with research and optimum practice around feeding and eating. They tend to use behavioral interventions that pressure the child to eat, exacerbate lack of interest in eating or food avoidance, and worsen the problem.
Work must be in proportion to the problem at hand
Correcting such a preponderance of problems with eating and feeding means there is plenty of work to go around. However, that work must be in proportion to the problem at hand, and it must be done by people who truly understand eating and feeding.
- Association AP. Feeding and Eating Disorders DSM-5: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDI T ION American Psychiatric Association; 2013:329-354
- Quick V, Byrd-Bredbenner C, White AA, et al. Eat, Sleep, Work, Play: Associations of Weight Status and Health-Related Behaviors Among Young Adult College Students. Am J Health Promot. Dec 20 2013.
- Lohse B. Facebook is an effective strategy to recruit low-income women to online nutrition education. J Nutr Educ Behav. Jan-Feb 2013;45(1):69-76.
- Lohse B, Bailey RL, Krall JS, Wall DE, Mitchell DC. Diet quality is related to eating competence in cross-sectional sample of low-income females surveyed in Pennsylvania. Appetite. 2011;58:645-650.
- Lohse B, Satter E, Horacek T, Gebreselassie T, Oakland MJ. Measuring Eating Competence: psychometric properties and validity of the ecSatter Inventory. J Nutr Educ Behav. 2007;39 (suppl):S154-S166.
- Satter EM. Eating Competence: definition and evidence for the Satter Eating Competence Model. J Nutr Educ Behav. 2007;39:S142-S153.
- Taylor P, Funk C, Craighill P. Pew Research Center; 2006.
- Sherry B, McDivitt J, Birch L, et al. Attitudes, practices, and concerns about child feeding and child weight status among socioeconomically diverse white, Hispanic, and African-American mothers. J Am Diet Assoc. 2004;104:215-221.
- Orrell-Valente JK, Hill LG, Brechwald WA, Dodge KA, Pettit GS, Bates JE. “Just three more bites”: an observational analysis of parents’ socialization of children’s eating at mealtime. Appetite. 2007;48:37-45.
- Galloway AT, Fiorito LM, Francis LA, Birch LL. ‘Finish your soup’: counterproductive effects of pressuring children to eat on intake and affect. Appetite. May 2006;46(3):318-323.
- 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.
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.
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