How Avoidant Restrictive Food Intake Disorder Is Diagnosed

Avoidant restrictive food intake disorder (ARFID) is a relatively new diagnosis. A person with ARFID limits the amount and/or type of food that they eat.

However, ARFID is much more than just being a "picky eater"—a person with ARFID might avoid a wide variety of foods because they have sensory sensitivity, apparent lack of interest in eating, or a concern of an adverse consequence of eating, such as a fear of vomiting or choking.

ARFID was first listed as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)—the handbook that mental health professionals currently use to diagnose eating disorders and other mental health conditions—in 2013. ARFID used to be referred to as "selective eating disorder."

ARFID Diagnostic Criteria

For a child, adolescent, or adult to be diagnosed with ARFID, they must meet certain diagnostic criteria that are outlined in the DSM-5.

To see if they fit the diagnosis, a person might need to have professional screenings and a medical assessment including lab tests. A healthcare provider will also need to come up with a differential diagnosis to rule out other possible conditions that could be the cause of the person's symptoms.

To be diagnosed with ARFID, a person must meet the following criteria.

A. The person experiences an eating or feeding disturbance that manifests as a failure to meet their appropriate nutritional and energy needs. This is demonstrated by at least one of the following:

• Significant weight loss, or faltering growth in children
• Significant nutritional deficiency
• Dependence on oral supplements or enteral feeding
• Marked interference with psychosocial functioning

B. The disturbance cannot be better explained by a cultural practice or lack of available food.

C. The disturbance does not occur as a result of anorexia nervosa or bulimia nervosa. There is no disturbance in body image.

D. The disturbance cannot be attributed to another medical or mental disorder.

While professionals think that most people with ARFID develop the condition as children, there are no diagnostic criteria related to the age of onset. A person of any age can be diagnosed with ARFID.

Professional Screenings

ARFID can be challenging to diagnose because it is a relatively new diagnosis, and more research is needed to validate the screening tools used to assess for it.

When assessing a person for ARFID, healthcare providers must also consider and rule out other medical and mental health conditions that could explain a person's symptoms.

There are several screening tools that providers can use to diagnose ARFID and differentiate it from other eating and feeding disorders. Several of these tools can be used in the diagnosis of ARFID and to differentiate it from other eating disorders.

Eating Pathology Symptoms Inventory (EPSI)

The Eating Pathology Symptoms Inventory (EPSI) is a 45-item self-report questionnaire. It uses eight subscales to measure various features of disordered eating, including Body Dissatisfaction, Binge Eating, Cognitive Restraint, Excessive Exercise, Restricting, Purging, Muscle Building, and Negative Attitudes Toward Obesity.

The EPSI is useful for differentiating between anorexia and ARFID. A 2016 study found that people with anorexia had higher scores in Cognitive Restraint than those with ARFID, but similar scores in Restricting.

Eating Disturbances in Youth–Questionnaire (EDY–Q)

The Eating Disturbances in Youth–Questionnaire (EDY-Q) is a 12-item self-report questionnaire that has been evaluated for diagnosing ARFID in school-age children ages 8 to 13.

The EDY-Q can help providers distinguish among emotional food avoidance, selective eating, food restriction due to fear of aversive consequences, and weight problems.

Eating Disorder Assessment for DSM-5 (EDA-5)

The Eating Disorder Assessment for DSM-5 (EDA-5) is a validated semi-structured interview that is designed to diagnose DSM-5 eating and feeding disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder.

While providers might use the EDA-5 to assess for ARFID, further research is required to validate it for diagnosing ARFID and other feeding and eating disorders.

Pica, ARFID, and Rumination Disorder Interview (PARDI)

The Pica, ARFID, and Rumination Disorder Interview (PARDI) is a semi-structured multi-informant interview that was created to diagnose ARFID in both children and adults.

The PARDI takes about 39 minutes to complete and is free to clinicians. It has been studied in patients with AFRID between the ages of 8 and 22 years old, but more research is needed to determine how useful it is.

Nine-Item ARFID Screen (NIAS)

The Nine-Item ARFID Screen (NIAS) is a Likert scale with nine statements. A Likert scale is a way to gauge the intensity of a person's response to a question or statement. For example, the scale may ask a person if they "strongly agree," "somewhat agree," or "strongly disagree" with a question.

An ARFID diagnosis is suspected if a person receives scores of greater than 10 on the NIAS picky eating subscale, greater than nine on the NIAS appetite subscale, and/or greater than 10 on the NIAS-fear subscales.

Researchers recommend that clinicians use the NIAS in combination with another validated eating disorder screening tool.

Labs and Tests

A thorough medical evaluation is an important part of the diagnosis process for ARFID. A person with ARFID can experience significant weight loss and deficiencies in vitamins and minerals that can impact growth and development, as well as long-term health.

During diagnosis, it is important for providers to screen patients for deficiencies and also rule out medical conditions that could account for a person's symptoms.

Recommended labs and tests during the ARFID diagnosis process include:

• Basic metabolic panel or comprehensive metabolic panel
• Complete blood count (CBC)
• Magnesium and phosphorous
• Iron, folate, and zinc
• Vitamins C, D, A, K, and B12
• Thyroid-stimulating hormone (TSH)
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein
• Urinalysis

Other diagnostic tests might be indicated to rule out specific conditions based on a person's symptoms.

Self-Tests

Some ARFID screening tools are available for free online, but these should always be followed up with assessment by a medical professional.

If you think that you or a loved one might have ARFID, it's important to talk to your doctor. Ensuring that you receive the correct diagnosis will help you get the appropriate treatment.

ARFID Is More Than "Picky Eating"

Knowing the signs and risk factors for ARFID can help you determine whether you need to talk to a medical professional. It's especially important for parents and caregivers to understand that ARFID is more than just "picky eating."

Many children have some level of picky eating, which usually involves avoiding one or two foods. However, if a child avoids a wide variety of foods and does not outgrow food avoidance, it's time to talk to their pediatrician.

Change in Eating Habits

New changes in eating patterns that were initiated by an episode of traumatic choking or vomiting can also be related to ARFID in both children and adults.

For example, a person who has a bad episode of food poisoning and begins to severely limit their diet for fear of another food poisoning experience would want to discuss the possibility of ARFID with their doctor.

Malnourishment

Malnutrition is a consequence of many eating and feeding disorders. If a person is malnourished, it might be because they have ARFID, another eating disorder, or a medical condition.

Signs and symptoms of malnutrition include:

• Fatigue
• Dizziness and fainting (syncope)
• Abdominal pain
• Constipation
• Cold intolerance
• Primary or secondary amenorrhea
• Dry skin
• Hair loss
• Fast heart rate (tachycardia) or low heart rate (bradycardia)
• Low blood pressure (hypotension)
• Weight loss
• In children, failure to reach their height and weight milestones

ARFID Subtypes

There are no official subtypes of ARFID detailed in the DSM-5. However, research has suggested that there could be three distinct subtypes of ARFID, based on clinical presentation.

These subtypes are:

1. Limited intake subtype: People with a lack of interest in eating that leads to weight loss and medical complications
2. Limited variety subtype: People with sensory sensitivity that results in restriction of foods
3. Aversive subtype: People with a fear of aversive consequences of eating that results in food avoidance

A 2018 study of 77 child and adolescent patients with ARFID, ages 8 to 17 years old, determined that 39% had limited intake, 18% had limited variety, and 43% had aversive subtypes.

Differential Diagnosis

Differential diagnosis is a process that medical professionals use to diagnose health conditions. The process includes testing for many possibilities and ruling out conditions one by one to help them make the correct diagnosis and provide the appropriate treatment.

Medical Differential Diagnosis for ARFID

Restrictive food intake can occur in a variety of medical conditions, including gastrointestinal diseases and food allergies and intolerances such as celiac disease.

Other medical conditions that should be ruled out when assessing a person for ARFID include:

• Cancers and malignancies
• Inflammatory bowel disease
• Addison's disease
• Pernicious anemia
• Hyperthyroidism
• Type 1 diabetes
• Infectious diseases
• Conditions that affect chewing and swallowing

Mental Health Differential Diagnosis for ARFID

Other mental health conditions should also be considered because some might explain a person's symptoms better than an ARFID diagnosis.

For example, if a person's disordered eating behavior is driven by body image distortion, a diagnosis of anorexia nervosa might be a better fit.

There are several mental health conditions that may share symptoms with ARFID, including:

• Anxiety disorders
• Autism spectrum disorder (ASD)
• Mood disorders
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)

Having ARFID and Another Condition

Sometimes people with another condition, such as OCD or autism spectrum disorder, also have ARFID. When a person has more than one condition, it's called comorbidity.

If a person with a specific mental health diagnosis demonstrates food avoidance that causes significant psychosocial, medical, and nutritional disturbances, experts recommend that the person also be diagnosed with ARFID.

A Word From Verywell

While the condition involves restrictive or limited eating patterns, ARFID is much more than being a "picky eater." ARFID is a serious mental health condition that can lead to delays in development and growth, as well as long-term effects on a person's health and well-being.

If you are concerned that you or a loved one might have ARFID, it's important to talk to a medical professional about what you are experiencing.

ARFID is a relatively new diagnosis and can be a challenge for healthcare providers to identify and differentiate from other disorders. However, a thorough evaluation, the use of the screening tools available, and tests to rule out other conditions can help make sure you get the correct diagnosis and the appropriate treatment.