Many kids go through picky eating phases. Avoidant/restrictive food intake disorder, or ARFID, is different.
Children with ARFID may eat too little or limit their diets so severely that it interferes with growth, nutrition, school, family life or social activities. Unlike eating disorders such as anorexia or bulimia, ARFID is not driven by body image concerns. A child may have little interest in food, strong sensory aversions or fear tied to choking, vomiting, allergic reactions or other distressing food experiences.
Now, a randomized clinical trial from Stanford Medicine offers stronger evidence for two treatment approaches in children with ARFID. The study, published in the Journal of the American Academy of Child & Adolescent Psychiatry, included 98 children ages 6 to 12 who met diagnostic criteria for ARFID and were low weight.
“This is the first study, worldwide, to take a systematic, randomized, adequately powered approach to testing treatments for this disorder,” said James Lock, MD, PhD, lead study author and a professor of psychiatry and behavioral sciences at Stanford Medicine.
The researchers randomly assigned participating families to one of two structured treatments. Both included 14 one-hour therapy sessions over four months, delivered online to families across the United States.
One approach, family-based therapy, focused on helping parents take an active role in changing ARFID-related eating behaviors, including eating too little, eating a very narrow range of foods or avoiding food because of fear. Children, parents, siblings and therapists participated together in the sessions.
“The therapist guides and consults them, but parents are the experts on their child, their family’s food culture and their family systems,” said Brittany Matheson, PhD, a clinical associate professor of psychiatry and behavioral sciences at Stanford Medicine.
The second approach, psychoeducational motivational therapy, was more child-centered. Children worked with therapists through individualized, play-based sessions designed to help them understand ARFID, explore their own motivation to eat differently and practice food-related changes. Parents also received education on ARFID, reducing conflict around meals and supporting their child’s goals.
By the end of the trial, both groups had significant improvement in ARFID symptoms. The family-based therapy group also gained a statistically significant amount of weight, while the individual therapy group did not. Children with more severe ARFID symptoms appeared to benefit more from family-based therapy than individual therapy when it came to weight gain.
“We now have two treatments that work for children aged 6 to 12 with ARFID,” Matheson said.
That does not mean families should try to treat ARFID on their own. The study tested structured therapy for children who had been diagnosed with ARFID and were low weight. Some children with ARFID need outpatient care, while others may need more intensive medical, nutritional, occupational or mental health support.
The findings also do not apply to every child who eats selectively. Picky eating is common in toddlers and preschoolers, and many children become more flexible with time. ARFID is more persistent and more disruptive. It can affect growth, nutritional status, energy, school performance and a child’s ability to participate in everyday activities involving food, from birthday parties to sleepovers to summer camp.
That distinction can be difficult for families. Parents may be told that a child will “grow out of it,” even when eating struggles are affecting health or daily life.
“Some ARFID patients are young people who don’t like to eat very much — they have a low appetite, or they are highly selective because they worry about feeling disgusted by foods,” Lock said.
Other children may restrict food after a frightening experience, such as choking or an allergic reaction. ARFID is also more common among children with attention-deficit/hyperactivity disorder, anxiety disorders and autism than in the general child population.
One child in the Stanford trial, Julia Ceresnak, joined the study in 2020 when she was 10. She worked with Matheson on strategies to try new foods, including tracking foods as “always,” “sometimes” and “not yet.” Over time, some foods moved from one list to another.
“That was very motivational for me, as a little kid,” Julia said.
At 15, Julia still receives ARFID treatment, but her motivation has changed. According to Stanford Medicine, therapy has helped her plan for camp, school trips and travel. Foods that were once off-limits, including avocado, eggs, yogurt with berries, edamame and pomegranate, have become part of her diet.
The trial gives families and clinicians more evidence in an area where treatment research has been limited. It also offers a more compassionate way to think about children who are struggling to eat. ARFID is not stubbornness, bad parenting or ordinary pickiness taken too far. For some children, eating is tied to fear, distress or a lack of internal motivation, and structured treatment may help them move toward a wider, safer and more nourishing relationship with food.
The study was funded by the National Institute of Mental Health.