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Session 1

Professionals – Selective Eating vs ARFID

Session 1

Introduction to feeding difficulties and ARFID

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WELCOME
TO SELECTIVE EATING VS AFRID - 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

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East London
NHS Foundation
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NELFT NHS Foundation Trust

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 impact on physiological, behavioural & emotional

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 Difficulty and ARFID

it needs a multidisciplinary team to assess for ARFID. Diagnosis can be challenging given some complex presentation. There is a huge overlap with Autism. It is important to rule out any medical condition that might be impacting the eating like: Gastro symptoms – low interoception, low pain tolerance, sensory sensitivity, Autism, anxiety ; Medication that might affect taste ; Somatic symptoms. 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, 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 / holidays
/ school / friends house)

Dilemmas

Strategies

Many different strategies can be used to treat both eating difficulties and ARFID. Not helpful to do when considering strategies:

Hiding foods they don’t like into foods they like

Letting them go hungry – they won’t eat anyway, even if hungry

Not giving their preferred food (especially if weight restoration isneeded). 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

To blame the parents – IT IS NOT PARENT’S FAULT!

Psychosocial aspect

Important aspects should be considered: eating out (at school, restaurants, holiday, other people house) can be a challenge, it needs further investigation about the severity of this (i.e. is able to eat at school when taking packed lunch or not even able to eat anything at all); Impact on family dynamic (i.e. constant stress and arguments, unable to eat at the table); Being able to engage socially when food is present (i.e. tolerating food during a sleep over). All these aspects need to be explored and understood better

What can we do to support the eating difficulties?

We know that routine works
well for most children

Think about offering 2/3 options
(maximum per day, so they also
engage on this)

Thinks about a visual timetable
and possibly a visual meal plan

Taking them to shopping and letting them
chosesome new foods

Reward system – can be helpful
with some children

To use hunger chart, to
help them track and
understand their hunger
signals

Having a separate cupboard can
be helpful sometimes

Distractions at meal times – can be helpful
in some cases, but ideally is a working in
progress to remove this so children can be
present whilst they are eating

What can we do to support
the eating difficulties?

Have your child 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 your 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 you are eating different things. This gives the child opportunities to be around different foods.

Have a familiar routine around mealtimes wash hands, set table, eat food etc.

When possible, ignore your child when he or she is 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 your child is sitting in a comfortable chair (feet on the floor)

Having a sensory box – example: fidget toys, stress balls (create together with the child)

It is important to offer foods your child already likes, as well as foods your child does not yet like. A good rule of thumb is to only offer three foods at a time. Include one to two foods your child already likes and one food your child does not yet like. If your child will not tolerate the new food on his or her plate, place the new food near him or her on a separate plate to help get your child used to the new food.

Present new foods in small bites and in fun or familiar ways to make it more likely that your child will eat it.

Parents working together (using same strategies) towards the same goal, so the child know what to expect

ARFID – what it is, what
it is not and treatment
strategies

Paola Falcoski

Advanced Specialist eating disorder dietitian

Sharon Thomson

Specialist Eating Disorder Nurse

Agenda

• ARFID diagnostic criteria
• Assessment
• Outcome measures
• Comorbidities
• Autism and ARFID
• Understanding that eating is a complex task
• Strategies for treatment
• The paediatrician role and medication
• What to expect
• Resources

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

1

Significant weight loss (or failure to gain weight or faltering growth in children)

2

Significant nutritional deficiency

3

Dependence on oral/enteral feeding

4

Marked interference with psychosocial functioning

ARFID is not...

Problems with weight that are related to body and shape concerns
Feeding problems that are related to scarcity of foods or any religion that has specific rules around food
Related to any medical or psychiatric condition (i.e. depression that might leads to reducefood intake and consequently weight loss).

When ARFID is present, usually...

Eat less than 20
types of food

Anxiety around
new food

Sensory-sensitivity

Contamination/
change in
textures – one
food can´t touch
the other

Is a more
developmental
rather then
acquire eating
disorder

Veggies and fruits
are very difficult –
texture, size,
flavour > no
pattern

Brown/beige
carbohydrate diet –
mashed potato, chicken, crisps...

Easier to manage in
terms of
texture/ smell/ bland
flavours

Smooth textures –
easier to manage

Loyalty to brand –
is about
predictability

Processed food -
know what to
expect (i.e. all
nuggets will be the
same)

THIS IS A BISCUIT

"I was eating my biscuit and suddenly was soft and I stopped eating it because biscuit should be crunchy" = if not crunchy is not 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 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 quick, not “liking” to eat, no interest in food or all together
- Fear of eating because it might cause vomiting, choking, gaging 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 not trying
- Thinking the food will make them sick/ vomit/ choke
- Not wanting to eat a food once eaten because it caused some reaction in the past (allergy, vomit, choke)

HEALTH CONSEQUENCES

- Weight loss
- Reduced hunger
- Vitamins and minerals 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 ay 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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My Notes

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