In the 2000’s and even earlier, it became apparent that the systems of classifications used to define eating disorders were inadequate to describe the entire spectrum of clinical presentations, especially in children. In the UK, Dasha Nicholls famously wrote: “Children into DSM don’t go,” and I couldn’t have agreed more.
A new classification is established
Then, finally, the DSM was changed to reflect some consensus about pediatric eating disorders among those of us who - across the world - see patients in this age group. The classification ARFID (Avoidant Restrictive Food Intake Disorder) was created. In some ways, this acronym is a catch-all for many conditions which may very well be biologically unrelated (e.g. selective eating, food phobia/functional dysphagia, variant anorexia nervosa) except that they involve aberrations of ingestive behavior, but it was a start.
I am frequently asked by other pediatric providers “Are you seeing a lot of ARFID? Because we are.” Yes, we see a lot of ARFID. Now that it has a name, it can be explained to insurance companies in a way they can grasp and children with these disparate conditions can actually receive help.
In fact, in our younger age group partial hospital program (under 12) we always have several children, frequently more than half of them, who carry this diagnosis along with those with classic anorexia nervosa.
The many faces of ARFID
So what are the kids with ARFID like?
- Variant anorexia nervosa: young children who eat too little to maintain weight and seem resistant to doing so despite having no stated fear of fat
- Failure to thrive: like the above, but with less acute onset, often failing to gain weight for reasons that have puzzled parents and pediatricians for years
- Those rare young people with low biologic drive to eat and no hunger cues, despite normal development and activity
- Chronic suppression of appetite due to stimulants or even “non-stimulants” prescribed for ADHD and the development of under-eating as a habit
- Psycho-social failure to thrive, sometimes categorized as neglect, not based on parental criminality but, rather, poor understanding of children’s needs and dietary requirements, disrupted eating in the family because of parental eating disorder, depression, poverty or other psycho-social factors
- Undiagnosed intellectual impairment (low IQ in the mild-moderate mental retardation range) and under-estimation on the family’s part of the child’s need for nutritional support and guidance. These kids look normal superficially and the professionals working with them have not suspected (don’t ask me why) the impairment
- Cancer cachexia (weight loss in patients with cancer) or post cancer ingestive issues
- Food phobia or functional dysphagia
In our youngest age group we have a lot of fun. We eat communally, we maintain a low threshold for tube placement to support brain recovery, we keep the activities developmentally appropriate and we focus a lot on school. These are kids, after all, young kids. And they do well.
Those of you out there who treat children, what are you seeing? Let’s share the experience for the sake of advancing the field.