Avoidant-Restrictive Food Intake Disorder (ARFID) is a mental health condition in which individuals either are not gaining weight or receiving adequate nutritional intake due to their own interfering behavior (American Psychiatric Association, 2013). Unlike the “traditional” eating disorders, individuals with ARFID are not attempting to restrict their weight due to body image concerns; rather, they engage in picky eating and similar behaviors that make them less likely to either gain weight or obtain adequate nutrients. ARFID is “picky eating” that actually interferes with someone’s life.
Although categorized as an eating disorder, many experts view ARFID as being more similar in its presentation to the Obsessive-Compulsive Disorder (OCD) spectrum of conditions. ARFID is typically identified in children, although the condition can certainly carry into adulthood. Many individuals with ARFID are underweight, while others may be overweight due to eating a narrow range of foods with poor nutritional content. Aside from the obvious health concerns, ARFID can lead to impairment in other areas of life, such as social functioning. Individuals with ARFID may avoid eating in the presence of others due to their restricted preferences, or they could fall victim to teasing when their unique way of eating is observed by others. The social challenges and compounded effects of poor nutritional status often make things more difficult for the sufferer as they age.
Individuals with ARFID are often very rule-based in their eating. For example, they may be willing to eat pepperoni pizza from Papa John’s, but not from Pizza Hut. Generally, their avoidance of foods can be broken into three categories (Thomas & Eddy, 2019):
1) Fear or disgust of the taste, texture or smell of certain foods
2) Fear of choking
3) Extremely low appetite or quick fullness
Treatment for ARFID involves using a multidisciplinary team of experts. First, someone’s pediatrician or primary care physician should be consulted to determine whether there have been any negative health effects of being either under- or overweight for height. This doctor can also help the individual set a goal weight. A dietitian or nutritionist should also be consulted to assist in creating a meal plan with the appropriate caloric content. A psychologist or mental health professional can then help the individual with goal-setting, rewards, and approaching (i.e., trying to eat) foods that cause fear and disgust.
Cognitive-Behavioral Therapy for ARFID (CBT-AR) is a research based protocol used by mental health professionals to address ARFID (Thomas & Eddy, 2019). The early stages of treatment for individuals who are underweight involve increasing the amount of food eaten in order to promote weight gain and alter the experience of fullness. The CBT-AR protocol recommends increasing eating of preferred foods (even if very limited in variety and nutritional content) before ‘graduating’ to trying to increase the variety of foods consumed.
Obviously, if you could tell someone “just eat more” and it were that simple, they wouldn’t need a mental health professional to work with them. The work is in figuring out how to help someone to eat more when they just aren’t very motivated. That’s why I created the concept of a “Plus One (+1)” reward system as motivation. Note: This system was designed as a reward system for children, managed with their parents’ help. I will refer to it this way in this post. Of course, the system could be adapted for an adult.
Note 2: The following advice is not intended as a stand-alone treatment. This is a helpful method to use within the context of CBT-AR and ARFID treatment that is completed under the supervision of mental health and medical professionals.
In trying to change any behavior, rewards (i.e., positive reinforcement) can be incredibly useful. To increase eating in someone who does not wish to eat more, rewards may play a key role.
First, let’s start with: What is a reward? To be positively reinforcing, the reward must actually be so desired that the child would be willing to do something unwanted (i.e., eating more than usual) to earn it. If your child is not motivated by $100, then $100 is not a reward.
Rewards can be tangible, but that is not essential. Here are some ideas of potential rewards for increasing eating:
50¢ 10 extra minutes of screen time Choosing the movie for family night
Going to the park Dollar Tree toys Play time with parents Visiting the pet store
First, have a conversation with your child to determine their preferred rewards and negotiate the number of points needed to earn larger rewards. Remember, kids’ preferences change constantly, so this may be an ever-evolving reward system.
Now, what is a Plus One (+1)? A plus one is just a cute name for earning rewards by eating slightly more than intended. Despite the name, there is no math involved, and parents can adjust this based on their own judgment. Essentially, a plus one is just asking your child to eat slightly more than they normally would to work toward expanding their stomach and, eventually, gaining weight. Here are some examples of what a Plus One (+1) could look like:
How should a Plus One (+1) opportunity be presented? Completely casually! There is no pressure and there is only a reward opportunity (no punishment for not eating more). A parent might say something like, “Kate, great job eating three baby carrots. If you eat one more, you can earn a plus one!” If the child refuses, the parent can just casually move on. If the child complies, the parent should either give them points or their reward immediately, depending on the reward system.
Notes on Parenting: It is HARD parenting a child who is not eating enough. Feeding your child is kind of one of the essentials of keeping them alive, and it can feel like you’re failing at that. But, the lower pressure you can keep this system, the more enjoyable it will be for your child.
Also, many parents of children with eating concerns have their own disordered
eating. Helping their child eat more can be very triggering for them. As a
parent, it may be beneficial to get your own mental health support during your
child’s treatment if you are finding it difficult to engage in their program.
The child might stay in the Plus One (+1) system for months, working on increasing their eating and building up skills to eventually be able to branch out to new foods. The second part of ARFID treatment generally involves exposure therapy, helping kids practice trying their non-preferred foods. The goal is not to love the new food, but simply to be able to tolerate it.
Although it can be challenging working with a child with ARFID, there are so many benefits to adapting their eating behaviors as early in life as possible. Parents can help prevent future problems with health, socializing, and increased overall flexibility in behavior that will truly make a difference in the child’s life.
I hope you find this reward system useful. Please comment below with any thoughts or suggestions.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Thomas, J.J. and Eddy, K.T. (2019). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, & Adults. Cambridge: Cambridge University Press.