Building a positive relationship with food and your body
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Professionals – Selective Eating vs ARFID
Introduction to feeding difficulties and ARFID
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WELCOME
TO SELECTIVE EATING VS ARFID - PROFESSIONALS
Welcome! For professionals who work with young people who have Avoidant/Restrictive Food Intake Disorder (ARFID) or avoid/restrict certain due to food sensory experiences (colour, smell, taste, texture, temperature etc.). Learn more about ARFID, a serious eating disorder, and develop ways to cope with food sensitivity, anxiety and fears. Use NHS-backed tools to support young people with ARFID.
The difference between selective eating and ARFID (Avoidant/Restrictive Food Intake Disorder).
Understanding hunger.
Managing anxiety around food.
You can download sessions once complete.
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- NELFT NHS Foundation Trust
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Selective eating vs. ARFID
Neophobia
- Rejection of new, unfamiliar foods.
- Usually presents in infancy - 18-24 months of age.
Picky/fussy eating
- Mild feeding difficulty.
- Some selectivity of foods and/or limited appetite.
Feeding disorder
- Moderate to severe feeding difficulty.
- Avoiding whole food groups.
- Significant physiological, behavioural and emotional impacts.
Selective eating vs. ARFID
Every child will have a phase where he will refuse new foods and will only eat preferred foods - this is expected and normal. As the child ages and becomes more familiar with specific foods, they will become less resistant to trying them (Dovey et al., 2008).
The severity of food neophobia is usually determined by the number of separate exposures it takes for the child to accept the food and at least try it. While most children will readily try a food after seven exposures, more severe presentations of food neophobia may require novel foods to be presented many more times before a child will accept it.
Some children will continue to have food difficulties – presenting as limited appetite or lack of interest in eating, sensitivity to texture/smell/taste/temperature/appearance of food, limited range of foods eaten and difficulties eating out. However, this will not lead to physical health consequences. Picky/fussy eating appears to be distinct from food neophobia but, like food neophobia, does not appear to merit clinical psychology attention (Kerzner et al., 2015).
Others will have severe food selectivity to the point of restricting a whole food group and this will have significant impact in their lives and on their physical health. In this case, it could be ARFID (Avoidant/Restrictive Food Intake Disorder) and it is important to seek support from medical professionals. For more information on ARFID, please continue to Session 2.
Dilemmas between eating difficulties and ARFID
A multidisciplinary team need to assess for ARFID as diagnosis can be challenging, given some complex presentation. There is also a huge overlap with autism. It is important to rule out any medical conditions that might impact eating, like gastro symptoms – low interoception, low pain tolerance, sensory sensitivity, autism, anxiety, medication that might affect taste and somatic symptoms. It is also important to rule out any oral-motor difficulty that makes the child unable to eat/chew/swallow.
Diagnosis
Red flags and when to talk to the GP:
- Ongoing poor weight gain or weight loss.
- Stunted height.
- Ongoing choking, gagging, coughing during meals.
- Ongoing problems with vomiting.
- Vitamin and mineral deficiencies (are they eating foods from all food groups).
- Aversion/avoidance of all foods in specific texture or food group.
- Impact on psychosocial functioning (i.e. difficulty with eating out in restaurants/on holidays/at school/at a friend's house).
Dilemmas
Strategies
Many different strategies can be used to treat both eating difficulties and ARFID. Things that are unhelpful to do when considering strategies include:
Hiding foods they don’t like in foods they like.
Letting them go hungry – they won’t eat anyway, even if hungry.
Not giving their preferred food (especially if weight restoration is needed). If weight is within normal ranges or overweight this can be discussed.
Having the idea of 'good' and 'bad' food – food is food.
Pressure to eat or finishing on time.
Blaming the parents – IT IS NOT THE PARENT’S FAULT!
Psychosocial aspect
Important aspects should be considered: eating out (at school, restaurants, holidays, other people's houses) can be a challenge, needing further investigation regarding the severity of this (i.e., whether they are able to eat at school when taking a packed lunch or not able to eat anything at all). The impact on family dynamics (i.e., constant stress and arguments, inability to eat at the table), and the ability to engage socially when food is present (i.e., tolerating food during a sleepover) also need to be explored and understood better.
What can we do to support eating difficulties?
We know that routine works
well for most children.
Think about offering 2-3 options
(at most) per day so they can slowly engage with new foods.
Think about a visual timetable and
possibly a visual meal plan.
Taking them to shopping and letting them
choose some new foods.
A reward system can be helpful
for some children.
Use a hunger chart to
help them track and
understand their hunger
signals.
Having a separate cupboard with
their own food and snacks can be
helpful sometimes.
Distractions at meal times can be helpful
in some cases, but ideally it is a work in
progress to remove these so children can be
present whilst they are eating.
What can we do to support eating difficulties?
Have the young person be part of the meal where possible – helping to prepare, setting the table, or just bringing their own plate to the table.
Encourage them to serve others food, even
if they are not serving themselves.
If possible, have a ‘learning plate’ in front of the child. They can serve a small amount of food on to this plate. There is no pressure for them to eat this food, but they can look/smell/touch/play with this food.
Have meals together as a family where possible, even if they are eating different things. This gives the child opportunities to be around different foods.
Have a familiar routine around mealtimes: wash hands, set the table, eat food, etc.
When possible, ignore the young person when they are doing things such as spitting, throwing or refusing food. Remember, you don’t want to encourage these behaviours by paying attention to them.
Make sure the young person is sitting in a comfortable chair (feet on the floor).
Have a sensory box containing items such as fidget toys and stress balls. Create the box together with the young person.
It is important to offer foods the young person already likes, as well as foods they do not yet like. A good rule of thumb is to offer only three foods at a time: include one to two foods they already like and one food they do not yet like. If they will not tolerate the new food on their plate, place it near them on a separate plate to help them get used to it.
Present new foods in small bites and in fun or familiar ways so they are more likely to eat it.
Parents should work together (using the same strategies) towards the same goal, so the child knows what to expect.
What is ARFID – Avoidant/Restrictive
Food Intake Disorder?
APPARENT LACK
OF INTEREST
IN EATING
FOOD AVOIDANCE BASED ON SENSORY CHARACTERISTICS OF FOOD
CONCERN ABOUT
AVERSIVE
CONSEQUENCES
OF EATING
Significant weight loss (or failure to gain weight or faltering growth in children).
Significant nutritional deficiency.
Dependence on oral/enteral feeding.
Marked interference with psychosocial functioning.
ARFID is not...
When ARFID is present, an individual usually...
Eats fewer than 20
types of food.
Has anxiety around
new food.
Experiences sensory-sensitivity.
Finds contamination/change in textures difficult, for example, one food can't touch the other.
Shows developmental signs rather than an acquired eating disorder.
Finds eating veggies and fruits very difficult. This is often because of texture, size, flavour with no pattern.
Has a brown/beige
carbohydrate focused diet mashed potato, chicken, crisps.
This is easier for them to manage in terms of texture/smell/bland flavours.
Finds smooth textures
easier to manage.
Is loyal to brands, which is about predictability.
Eats a large amount of processed food as they know what to expect (i.e. all nuggets will be the
same).
This is a biscuit
"I was eating my biscuit and suddenly it was soft and I stopped eating it because a biscuit should be crunchy" = If the biscuit is not crunchy isn't a biscuit and therefore is not 'safe'.
This is NOT a biscuit
"I have trouble eating other brands I'm not familiar with; an example of this would be different brands of digestive biscuits.
The reason is partly because the biscuits of a different brand are unfamiliar to me but also 'unsafe', as the ingredients of a different brand differ to what I'm now familiar with and feel safe to consume."
This is NOT contaminated
"Once food is prepared in my own 'contamination free' method it is then packed into individual foil parcels.
These foil parcels are then placed on a fresh piece of foil and transported to a private place where I can sit and eat without being watched in fear of being judged."
This is contaminated
"Another element to my eating issues is around contamination and germs,
particularly around food preparation
which includes handling and storing food.
For this reason I have trouble allowing anyone else to prepare or handle
my food. I store my food separately where only I have access to it."
Things you might have noticed...
- Sensitive to smell, look, taste, texture or all together.
- Not feeling hungry, forgetting about eating, feeling full very quickly, not 'liking' to eat, no interest in food or all together.
- Fear of eating because it might cause vomiting, choking, gagging or all together.
- Anxious temperament.
Negative feelings about food
- Fear of new foods and not wanting to try new foods.
- Smelling the food before trying.
- Thinking that it won’t taste good anyway so it might be better to not try the food.
- Thinking the food will make them sick/vomit/choke.
- Not wanting to eat a food again because it caused some reaction in the past (an allergy, vomiting, choking).
Health consequences
- Weight loss.
- Reduced hunger.
- Vitamin and mineral deficiencies.
- Difficulty in gaining weight.
- Gut symptoms (i.e. upset stomach).
- Feeling full quickly.
- Constipation.
- Not getting taller.
Acting differently around food
- Not eating at the dining table.
- Finding it difficult to eat at school.
- Not eating in front of other people.
- Not feeling hungry/not being able to say they are hungry.
- Feeling uncomfortably full.
- Sensitive to changes on how food looks.
- Noticing small changes in food and its packaging (i.e. if the package has a different colour).
- Getting angry when they are forced to eat.
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