ARFID in Autism: Essential Strategies for Managing Eating Difficulties
Overview: This article explores Avoidant/Restrictive Food Intake Disorder (ARFID) ~ what it is, its prevalence in the autistic community, its subtypes of the condition, and common treatment approaches.
ARFID is an eating disorder characterized by an abnormal aversion to foods that causes nutritional deficiencies, weight loss, and related social struggles. Dissimilar to most eating disorders, ARFID is not due to body image or self-esteem issues. The estimated prevalence of ARFID in the wider population is estimated at 1.98% (Van Buuren, et al. 2023); however, it is estimated that up to 33% of the autistic population will struggle with ARFID at some point in their lives (Kozak et al, 2023). This makes management of ARFID symptoms a critical need of many autistic individuals.
ARFID Overview
ARFID is diagnosed when food avoidance reaches a level where it poses a threat to an individual’s functioning vis a vis weight loss, social interruption, health issues or other problems. ARFID typically develops during adolescence, but it is not uncommon for autistic individuals to experience some symptoms throughout their lives. On a day-to-day basis ARFID manifests as a refusal to eat, fear of trying new foods, lack of appetite, unawareness of hunger cues, and/or anxiety about getting sick from food.
Research shows that ARFID is more prevalent in the autistic community in no small part because autistics are more prone to experiencing issues with restricted interests and repetitive behaviors. Autistic individuals may hyperfocus on limiting their food intake to a few specific items, to only eating at certain times or in certain places, and avoiding any new or novel foods. To a lesser extent, some ARFID symptoms are caused by food anxiety, social competency issues, or issues with coordination and feeding. Regardless of the cause, ARFID can be broken down into three subtypes: avoidant, aversive, and restrictive, with each profile showing different symptoms and requiring different treatment approaches.
Avoidant ARFID:
Avoidant ARFID is demonstrated by avoiding specific sensory experiences such as a smell, texture, flavor, or feeling associated with food. This typically results in the individual having an overly narrow diet of foods which can lead to nutritional deficiencies as well as social difficulties from the person’s unwillingness or inability to eat out of their comfort zone.
Aversive ARFID:
Aversive ARFID is demonstrated by avoiding certain foods or avoiding eating altogether due to anxiety and fear about what could happen, such as fears of choking, feeling nausea, vomiting, or other potential health issues. This is commonly brought on by earlier negative experiences that become generalized to whole categories of food or the act of eating.
Restrictive ARFID:
Restrictive ARFID is demonstrated by avoiding food purely out of a lack of interest in eating or awareness of the necessity of nutrition. This is common with individuals who lack an awareness of their bodily sensations such as hunger cues and diminished energy, and who have no interest in food and do not enjoy the process of eating so that it is a chore rather than a pleasure.
ARFID Treatment Approaches
Treatment for ARFID depends heavily on the severity of symptoms, initial causes of the symptoms, and age of the individual. It is recommended that individuals and families struggling with ARFID collaborate with doctors, mental health professionals, and dietitians or feeding therapy specialists who have experience with both autism and disordered eating. Unfortunately, research on treatment of ARFID outside of childhood is severely lacking. While older individuals may extrapolate from the existing research on younger populations, there is a need to tailor these approaches to more mature and engrained ARFID patterns. Common treatment approaches are explored below.
SOS (Sequential-Oral-Sensory) Therapy
Dr. Kay Toomey Ph.D. (2010) developed this interdisciplinary approach to help clients build feeding routines, develop feeding skills, and understand food types while gradually reinforcing increased food exposure. SOS is primarily used with younger children, but many of the skills are applicable for older individuals who avoid eating. This approach has shown to be successful with Avoidant and Aversive ARFID symptoms.
Cognitive Behavioral Therapy (CBT)
Treatment to manage troubling thoughts, uncomfortable emotions, and problematic behavioral patterns is a common approach for ARFID. CBT can help to build anxiety management skills as well as break unhelpful thought and behavioral patterns. This is especially effective with Aversive and Avoidant ARFID symptoms.
Alexithymia Skill Development
This approach helps individuals build internal awareness and become more attuned to their bodies. By doing so, individuals can better recognize hunger cues, drops in energy, and understand the need for feeding. This may not help the individual enjoy food, but it can help them to understand the need to eat. This is especially effective with Restrictive ARFID symptoms.
Family Based Therapy (FBT) for ARFID
This approach encourages the whole family to develop a non-judgmental, empowered, and practical method of gradually increasing acceptance of new food behaviors (Lock et al. 2019). It can be adapted for Restrictive and Aversive ARFID symptoms.
Conclusion
ARFID is a common and potentially life-threatening problem within the Autism community. It is important for individuals to understand the roots of the disorder as well as the seriousness of its health implications. Treatment varies significantly depending on the etiology of the symptoms and age of the individual, but improvement is possible so long as the condition is accurately and adequately addressed.
For more information, check the following sources and/or speak with a coach at Autism Learning Lab:
Find an SOS Trained Therapist at:
“Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder” by Jennifer Thomas and Kamryn Eddy
References
Toomey, K. (2010). Introduction to the SOS Approach to Feeding Program. Retrieved from: https://sosapproachtofeeding.com/wp-content/uploads/2019/02/SOS-APPROACH-explanation-for-parents.pdf
Kozak, A., Czepczor-Bernat, K., Modrzejewska, J., Modrzejewska, A., Matusik, E., & Matusik, P. (2023). Avoidant/restrictive food disorder (ARFID), food neophobia, other eating-related behaviors and feeding practices among children with autism spectrum disorder and in non-clinical sample: A preliminary study. International Journal of Environmental Research and Public Health, 20(10), 5822.
Lock, J., Robinson, A., Sadeh‐Sharvit, S., Rosania, K., Osipov, L., Kirz, N., ... & Utzinger, L. (2019). Applying family‐based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa. International Journal of Eating Disorders, 52(4), 439-446.
Van Buuren, L., Fleming, C.A.K., Hay, P. et al. (2023). The prevalence and burden of avoidant/restrictive food intake disorder (ARFID) in a general adolescent population. J Eat Disord 11, 104.
