Eat Your Peas, Sweetie: Picky or Avoidant?

How many times in your life has your mother said, “Eat your peas, sweetie?” Do you remember that ungodly pile of green spheres just protruding like a mountain on the very edge of your plate? You just could not stand the thought of eating them.

For most children, vegetables and healthy eating are less appealing than the contents of a cookie jar in the snack cabinet, so in the more early stages of life labeling a child as a “picky eater” is not uncommon; however, some children and even adults face a full agenda of measures every day in order to avoid certain foods, or food at any cost. This general lack of interest in eating, especially in children, may significantly impact a child’s growth and development (American Psychiatric Association), and may ultimately meet the criteria of an eating disorder known as avoidant/restrictive food intake disorder (ARFID). As an article on the blog Mealtime Hostage says, “It’s not about the food.”

According to the American Psychiatric Association’s 5th edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-V), avoidant/restrictive food intake disorder (ARFID) is characterized by an “avoidance or restriction of food intake” that is “clinically significant [in the] failure to meet requirements for nutrition or insufficient energy intake through oral food intake” (American Psychiatric Association). While DSM-V criteria for ARFID states that the eating disorder cannot be the consequence of another eating disorder, medical condition, food insecurity, or cultural observance (i.e. fasting during religious holidays, such as Ramadan), ARFID can coexist with other conditions or disorders with the exceptions of anorexia and bulimia nervosa (AN and BN). Some other important features that must be present for the diagnosis of ARFID are “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; or marked interference with psychosocial functioning” (American Psychiatric Association 2013).

Individuals with ARFID are not just “picky eaters.” Preliminary research conducted by Norris et al. between 2014 and 2016 suggests that those who meet the criteria for an ARFID diagnosis “share similarities, yet distinct differences from other established eating disorders” (Norris et al. 2014; Norris et al. 2016). Some of these “distinct differences” that are similar among ARFID individuals include abdominal pain, a history or fear of vomiting or choking, and gastroesophageal reflux disease (American Psychiatric Association 2013; Eddy et al. 2015), which are atypical signs and symptoms as compared with what is typically reported in the more well-known eating disorders (i.e. AN, BN, and binge eating disorder, or BED). The key characteristic of ARFID is the avoidance of foods based on their appearance, smell, and texture, which is most likely why parents and caregivers may often perceive their children as “picky” because children may be uncomfortable or ashamed to admit that they are also avoiding or restricting food intake to prevent abdominal pain, vomiting or choking, or even the pain that comes with a gastro-related condition (diagnosed or undiagnosed).

Sometimes telling someone to eat something is a force against their will, which is a common problem between parents and their children. Perhaps the reasons that an individual, young or old, may choose not to eat are more complicated and interrelated than what had previously been foreseen. In a home environment more conducive to discussing abnormal eating behaviors and open to clinical diagnosis and intervention, children may be more ready to ask for clinical help. Developed by Crist et al. in 1994, the most consistent reliability and validity ARFID assessment tool known as the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) is used by clinicians to screen for ARFID in children more appropriately and accurately (Dovey et al. 2013). BPFAS has fortunately allowed the differentiation between ARFID and food neophobia, or fear of new foods, in typically developing children, which is gauged by the following three components: “lack of dietary variety, sensory sensitivity or defensiveness specific to food, and problematic behavior during mealtimes (e.g. spitting out food, hand batting food away, and packing)” (Dovey et al. 2016). Another tool known as the Child Food Neophobia Scale (CFNS) can be used side-by-side with BPFAS to screen for clinically relevant food avoidance in the population and increase clinician confidence in screening for ARFID versus typical age-related food neophobia; thus, with these robust screening tools children and adolescents can get the help they need before their health is even further jeopardized.

A final question that we need to address is whether ARFID can manifest itself into adulthood. According to Kelly et al., clinicians have noted that an ARFID diagnosis, while more commonly developed at a younger age, may also be found in older individuals who have gone without diagnosis or treatment of ARFID beyond their adolescence. Adults with ARFID may have a recorded history of anxiety disorders, or in some instances, neurodevelopmental disorders, such as attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Other possible illnesses that may be present at a later age of onset are anorexia nervosa or bulimia nervosa, but both Dovey et al. (2013) and Fisher et al. (2014) have only proposed the potential of comorbidity with these other eating disorders without extensive supporting evidence since data is lacking on the correlation between ARFID and AN and/or BN. Finally, although no evidence-based guidelines for ARFID-specific treatment exist currently, adults with ARFID can work with a registered dietitian nutritionist (RDN), as suggested by the results published by Ozier et al. (2011). These results have shown significance when adults with avoidant and restrictive feeding and eating behaviors have consulted with RDNs, especially since RDNs can monitor individuals’ weight status and the degree of nutritional deficiency effectively enough to detect and intervene not only the relative properties of ARFID but also other potential eating disorders and mental health conditions.

Eating disorders are more complicated than what the eye perceives; a person struggling with an eating disorder may not “look” like they are struggling, and multiple episodes of avoidant or restrictive eating may not be just “picky” eating, whether in children or adults; however, what has been proven to help many cases of eating disorders, mainly ARFID, is clinical intervention through clinicians properly trained to aid in age-appropriate treatment and recovery. Individuals with ARFID, such as McKaelen, can walk us through their experiences one step at a time and whenever they are ready, which is something we should consider when discussing a topic as sensitive as the eating disorder itself.

On a brighter note, if you are interested in learning more about how ARFID affects individuals that may include your friends, family, or even yourself, check out these great blogs that have interesting yet informative posts: PEA, French Fry Lady, and Mealtime Hostage. Remember that you are never alone.



American Psychiatric Association, eds. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Press, 2013. pp. 329-338.

Eddy K.T., Thomas J.J., Hastings E., et al: Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. Int J Eat Disord 2015; 48: pp. 464-470.

Fisher M.M., Rosen D.S., Ornstein R.M., et al: Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A “new disorder” in DSM-5. J Adolesc Health 2014; 55: pp. 49-52.

Kelly N.R., Shank L.M., Bakalar J.L., and Tanofsky-Kraff M.: Pediatric feeding and eating disorders: Current state of diagnosis and treatment. Curr Psychiatry Rep 2014; 16: pp. 446.

Norris M.L., Robinson A., Obeid N., Harrison M., Spettigue W., and Henderson K.: Exploring avoidant/restrictive food intake disorder in eating disordered patients: A descriptive study. Int J Eat Disord 2014; 47: pp. 495-499.

Norris M.L., Spettigue W.J., and Katzman D.K.: Update on eating disorders: Current perspectives on avoidant/restrictive food intake disorder in child and youth. Neuropsychiatr Dis Treat 2016 Jan 19; 12: pp. 213-218.

Ozier A.D., and Henry B.W.: Position of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders. J Am Diet Assoc 2011; 111: pp. 1236-1241.

T.M. Dovey, C. Jordan, V. Aldridge, C. Martin. Screening for feeding disorders: Creating critical values using the behavioral paediatrics feeding assessment scale Appetite, 69 (2013), pp. 108–113.

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