CBT for Avoidant/Restrictive Food Intake Disorder (ARFID)

Cognitive-behavioral therapy (CBT) is a treatment that can be used for children, families, and adults with Avoidant/Restrictive Food Intake Disorder (ARFID).

CBT involves learning how thoughts, behaviors, and emotions are linked:

Exposure therapy is a type of CBT that involves gradually facing one's fears in order to tackle unhelpful anxiety. Gaining exposure to the fear trigger helps someone to challenge unhelpful thoughts and behaviors. This is how they get back into life and keep the fear from disrupting school/work, family/home life, their social life, health, or other important areas of functioning. Read my previous post for more detail.

ARFID is an “eating disorder” that has nothing to do with trying to lose weight or be thin. It is characterized by avoidance of food/eating and anxiety or disgust about foods based on their sensory profile or potential consequences, such as choking.

For a subset of kids, picky eating takes on a life of its own. They might only have a rotation of 5 foods that they are willing to eat. They may have strong brand preferences, accepting Tyson chicken nuggets and rejecting the Kroger brand. Perhaps they restrict foods based on their smell, texture, color, or temperature.

These children are not eating within all the food groups and they may be developing nutritional deficiencies. They might be noticeably underweight or overweight. Their eating is starting to impact their daily lives: either their family functioning (e.g., arguing, parents having to make separate meals), school life (e.g., not able to eat school lunch), or social life (e.g., not able to eat at friends’ houses). Their worlds become smaller and smaller and their health is at risk. While this likely begins in childhood, sometimes the picky eating does not resolve and continues into adulthood, causing even more impairment..

ARFID was not formally recognized by mental health professionals until 2013, so the research on treatment is somewhat lacking. There are, however, CBT strategies that work really well.

Unless someone’s physical health is severely impacted by the condition, generally ARFID can be treated by only a mental health professional in an outpatient setting (e.g., once-a-week therapy), monitored by a medical doctor, and a dietitian is optional. Unfortunately, most providers are unfamiliar with ARFID, and it is hard to know where to place these kids and adults.

Treatment is based on the three subtypes:

• For someone with a low appetite and/or low interest in eating who is underweight, they learn strategies to eat more in a sitting and day and gain weight until they are a healthy weight for their height.

• For someone with sensory sensitivities (picky eating based on the smell, texture, perceived taste, color, etc. of food), they engage in exposure therapy to learn to taste a new/unfamiliar/avoided food and begin incorporating it into their regular weekly diet.

• For someone who is afraid of choking or vomiting on food, they engage in exposure therapy to the feared food and begin re-incorporating it into their regular weekly diet.

Some kids with develop ARFID because of difficulty with a food allergy, which can also be addressed in treatment.

Many kids on the autism spectrum develop ARFID. They are able to engage in treatment with some tailoring for their unique needs.

Adults who are motivated to change their eating behavior can proceed as normal in CBT treatment. Generally, kids and teens are able to engage in this treatment as well.

In some families, either the child/teen is completely resistant to treatment or the whole family system is very wrapped up in the ARFID. There are treatment strategies that involve the parents/caregivers more than the child, if needed.