On April 9th, 2025, Amanda Smith, LICSW, LCSW, LCSW-C, CEDS, Monte Nido Executive Director Virtual Adolescent Programs and Kamryn Eddy, Ph.D., Co-Director, Eating Disorders Clinical and Research Program, Massachusetts General Hospital professor of psychology, Department of Psychiatry, Harvard Medical School, presented “ARFID: Understanding Diagnosis and Treatment.”
What is ARFID?
ARFID (avoidant/restrictive food intake disorder) is an eating disorder or feeding disturbance manifested by persistent failure to meet appropriate nutrition and/or energy needs associated with one (or more) of the following symptoms:
1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
2. Significant nutritional deficiency
3. Dependence on enteral feeding or oral nutritional supplements
4. Marked interference with psychosocial functioning
Additionally, the disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. The symptoms do not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of body dysmorphia, or the way in which one’s body weight or shape is experienced. The eating disturbance is not attributed to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
It is important to remember that individuals struggling with ARFID are still humans living in a world that has a lot of body ideals, norms, and expectations, and that mindset may still be present.
ARFID in adults vs ARFID in adolescents
ARFID impacts individuals of all ages. For adults with ARFID, they may struggle with aspects of their career, including company outings or client lunches, difficulty engaging in age-appropriate activities such as dating, weddings, and vacations, and are often described as eating like a “bird” or a “child.” It is important to recognize ARFID in adults because it is often viewed as a pediatric and adolescent condition.
Adolescents may face challenges engaging in activities with peers such as sleepovers, school or family gatherings, and often have providers conclude that they will outgrow these symptoms. Adults and adolescents face similar challenges, although they may have a different impact in adulthood, especially if they experience career repercussions.
ARFID's three symptom presentations
ARFID has three main symptom presentations:
- Sensory sensitivities (color, taste, texture)
- Fear of aversive consequences (choking, GI distress, vomiting, allergic reactions)
- Lack of interest (limited appetite, lack of enjoyment from eating, apathy towards eating).
There are mixed presentations of ARFID - individuals can struggle with any or all of the ARFID profiles, which are categorized differently than subtypes used in other eating disorder diagnoses. ARFID is a heterogenous illness, and there is a shared pathology for kids and adults, but the rationales and consequences can be different.
ARFID and other eating disorders
The DSM-5 says that if people meet criteria for anorexia or bulimia, they cannot also be diagnosed with ARFID. However, according to research, this isn’t always true.
In one study, individuals may have met the criteria for ARFID and later met criteria for anorexia nervosa. It is expected for weight concerns to not be a primary driver in ARFID, but that doesn’t mean that it won’t be present. Research shows that there are people who fall into diagnostic categories of ARFID and anorexia nervosa or bulimia nervosa, which differs from what is detailed in the DSM-5. There is a clear subset of individuals with ARFID who have weight concerns, but not the primary driver of restrictive eating. However, these weight concerns can interfere with recovery (Thomas et al., 2017; Curr Pscyhiatry Rep, Abber et al., 2025; Psychol Med. Kambanis et al., 2025, JAACAP).
ARFID and co-occurring disorders
Individuals may present with ARFID as well as co-occurring disorders, which can make treatment more complex. Common co-occurring conditions include:
- anxiety disorders, which have the highest rate of co-morbidity
- depressive disorders
- ADHD
- autism spectrum disorder
- GI conditions
- food allergies
ARFID and its relationship with GI conditions, allergies, or psychiatric disorders is bi-directional. Experiencing these conditions may alter experiences with food, making individuals vulnerable to developing disordered eating, and in-turn, struggling with an eating disorder may change how individuals interact socially, causing vulnerabilities to disorders such as anxiety.
It is important to consider how treating co-occurring disorders may impact the treatment of ARFID, and vice versa. Many strategies for treating ARFID can also aid in addressing other struggles.
How to identify ARFID in clients
Additional factors in identifying individuals with ARFID include delays in eating behaviors, difficulty with food exploration, and lack of knowledge. As you work through textures, tastes, and other obstacles with your client, it is important to be attentive to signs that other referrals may need to be placed.
Food explorations can be complicated by potential traumatic experiences, food allergies, or limited exposure to variety of foods, which can increase emotions related to trialing new foods. Remember, food explorations are hard to do. It is necessary to pause and validate the difficulty of this stage and re-regulate expectations.
CBT-AR treatment for ARFID
We are still learning how best to treat ARFID. A new treatment, developed by our speakers, is CBT-AR (Cognitive Behavioral Therapy for Avoidant/Resistant Food Intake Disorder). This treatment has four stages that take place over 20-30 outpatient sessions but can be adapted to a higher level of care as well. This treatment is designed for clients ages 10+ but can be altered for younger clients.
The first stage helps the client and family learn about ARFID and identify which presentation they are struggling with, while actively focusing on weight restoration. Stage two tries to take stock and make a game plan for stage three, providing a foundation of nutrition education and how to meet both nutritional and psychosocial needs. Stage three is the heart of treatment and capitalizes on principles of exposure to foods, teaching the antidote to avoidance. The fourth stage is relapse prevention, setting up a game plan, and reviewing the tools needed to be a life-long food learner.
FBT can also be modified to FBT-ARFID, with a focus on treatment, role of family, and treatment phases including food exploration, eating vs. weight restoration, and returning to meeting developmental milestones.
Going forward, we need to continue to provide opportunities to increase community/provider knowledge of ARFID, increase network of providers trained to treat ARFID, and continue ongoing research efforts to better understand ARFID and effective treatment methods, with the goal of helping clients find fulfilment.
Resources:
CBT-AR patient/family workbook
Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorders: Children, Adolescents, & Adults (Thomas & Eddy, 2019)
Pica, ARFID, and Rumination Disorder Interview and questionnaire
The Picky Eater’s Recovery Book: Overcoming Avoidant/Restrictive Food Intake Disorder (Thomas, Becker, & Eddy, 2021)
