ARFID: A Still Underrecognized Eating Disorder

Article written in collaboration with @dott.ssa_giuliagiulivi

Avoidant/Restrictive Food Intake Disorder (ARFID) was introduced as an independent diagnostic category in the DSM-5, replacing and expanding the previous definition of "feeding disorder of infancy or early childhood" (American Psychiatric Association, 2022). Unlike anorexia and bulimia nervosa, ARFID is not driven by a desire to control body weight or shape, but by an avoidance or restriction of food intake that can stem from three mechanisms, which often co-occur: heightened sensory sensitivity to specific characteristics of food, fear of aversive consequences related to the act of eating (such as choking or vomiting), and a low interest in food or eating in general (American Psychiatric Association, 2022; Zickgraf & Ellis, 2018).

How Common Is It

Prevalence estimates vary considerably depending on the setting. A systematic review on the epidemiology of ARFID in children and adolescents found that studies from non-clinical samples reported prevalence estimates ranging from 0.3% to 15.5%, while most studies from specialised eating disorder services reported prevalence rates of 5%–22.5%, and three studies from specialist feeding clinics showed the highest rates, ranging from 32% to 64% (Sanchez-Cerezo et al., 2023). The same review noted that psychiatric comorbidity was common in this population, particularly anxiety disorders (9.1%–72%) and autism spectrum disorder (8.2%–54.75%) (Sanchez-Cerezo et al., 2023). This variability reflects both the relative novelty of the diagnosis and the lack, until recently, of standardized screening tools at the international level.

How It Is Clinically Assessed

One of the most important developments of the past decade concerns assessment tools. The most comprehensive clinical interview currently available is the PARDI (Pica, ARFID, and Rumination Disorder Interview), which allows clinicians not only to confirm the diagnosis but also to measure the severity of each of the three profiles — sensory, low interest, and fear of aversive consequences — as well as the disorder's functional impact (Bryant-Waugh et al., 2022). Alongside the PARDI, which takes about 45 minutes and requires trained personnel, faster tools have been developed such as the EDA-5 and the ARFID module of the EDE, as well as self-report questionnaires like the NIAS (Nine Item ARFID Screen) and the PARDI-AR-Q, designed for initial screening when a structured clinical interview isn't feasible (Bryant-Waugh et al., 2022; Zickgraf & Ellis, 2018). In clinical practice, when ARFID is suspected, guidelines recommend always pairing a psychological assessment with a medical evaluation, to rule out organic causes and monitor potential nutritional deficiencies (Clinical Management of ARFID, 2021).

Differential Diagnosis: Distinguishing ARFID from Other Presentations

One of the most delicate clinical challenges is distinguishing ARFID from other conditions with which it shares some surface-level features:

• ARFID vs. anorexia nervosa: both involve food restriction, but in anorexia the restriction is driven by fear of weight gain and a distorted body image, elements absent in ARFID (American Psychiatric Association, 2022).

• ARFID vs. "physiological" picky eating: a useful framework for clinical practice is the BBI model (Behaviour, Belief, Impairment), which encourages clinicians to assess not only the eating behavior itself but also the underlying beliefs and, above all, the functional impact on the person's life (Clinical Management of ARFID, 2021).

• ARFID vs. gastrointestinal disorders: in patients with disorders of gut-brain interaction, food restriction can begin as a strategy to avoid digestive symptoms, gradually developing into a presentation that overlaps with ARFID; a substantial proportion of these patients are estimated to show ARFID-related symptoms (Journal of Clinical Psychology in Medical Settings, 2026).

Comorbidities and Risk Factors

ARFID rarely occurs in isolation. It is particularly frequently associated with anxiety disorders and, in a considerable proportion of cases, with autism spectrum conditions: a recent meta-analysis estimated considerably higher co-occurrence rates between autism and ARFID compared to the general population (Sader et al., 2025). ADHD is also more common in this clinical population, as are the functional gastrointestinal disorders mentioned above.

What Happens If It Goes Unrecognized

ARFID can emerge at any age, but typically arises in childhood; if unidentified, it tends to persist into adulthood, progressively becoming complicated by other medical or psychiatric conditions (StatPearls, 2024). In adults, the clinical picture can present differently than in children — less tied to overt avoidance and more rooted in chronic, restricted eating habits, often masked by a social life organized around avoiding risky situations (dining out, travel, new settings). Medical consequences can include vitamin and mineral deficiencies, significant weight loss, growth failure in children, and, in the most severe cases, the need for artificial nutritional support (Clinical Management of ARFID, 2021).

How It Is Treated

Until a few years ago, there was no treatment protocol specific to ARFID, and clinicians often adapted approaches designed for anorexia and bulimia, with limited results precisely because the underlying psychopathology is different. A significant shift came with the development of CBT-AR (Cognitive-Behavioral Therapy for ARFID), a protocol structured in stages that integrates psychoeducation, treatment planning tailored to the patient's profile, and gradual exposure to food (Thomas & Eddy, 2018). The model involves family participation in pediatric cases and adapts the course of treatment based on age and severity, with particular attention to building trust before proceeding with exposures — a crucial element when restriction stems from fear or trauma.

Why It Matters

Diagnostic delay remains one of the main problems: many families and adults live with ARFID for years, believing it is simply "pickiness" or a difficult temperament at the table. The assessment tools available today allow for more timely and accurate recognition — an essential condition for intervening before significant nutritional deficiencies set in, or before avoidance becomes so entrenched that it significantly compromises quality of life.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Bryant-Waugh, R., Micali, N., Cooke, L., Lawson, E. A., Eddy, K. T., & Thomas, J. J. (2022). Development of the Pica, ARFID, and Rumination Disorder Interview (PARDI): A multi-informant, semi-structured interview of feeding disorders across the lifespan. International Journal of Eating Disorders.

Sader, M., Weston, A., Buchan, K., Kerr-Gaffney, J., Gillespie-Smith, K., Sharpe, H., & Duffy, F. (2025). The co-occurrence of autism and avoidant/restrictive food intake disorder (ARFID): A prevalence-based meta-analysis. International Journal of Eating Disorders, 58(3), 473–488. https://doi.org/10.1002/eat.24369

Sanchez-Cerezo, J., Nagularaj, L., Gledhill, J., & Nicholls, D. (2023). What do we know about the epidemiology of avoidant/restrictive food intake disorder in children and adolescents? A systematic review of the literature. European Eating Disorders Review, 31(2), 226–246. https://doi.org/10.1002/erv.2964

Thomas, J. J., & Eddy, K. T. (2018). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Children, adolescents, and adults. Cambridge University Press.

Zickgraf, H. F., & Ellis, J. M. (2018). Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): A measure of three restrictive eating patterns. Appetite, 123, 32–42. https://doi.org/10.1016/j.appet.2017.11.111