ARFID and the Three Presentations

Sensory differences, low interest, and fear of aversive consequences

One of the most useful things to understand about ARFID is that it does not look the same in everyone.

Two people with ARFID may eat very different foods, eat very different amounts, and experience food and eating in very different ways.

Understanding what is contributing to the restriction is important because support needs to reflect the individual person rather than simply the fact that their eating is restricted.

This fact sheet explains three commonly recognised ARFID presentations:

These are not rigid categories, and a person may experience features of more than one at the same time.^1–4

This fact sheet provides general information rather than a diagnosis. An appropriate clinical assessment is needed to establish whether someone has ARFID and what may be contributing to their eating.

A quick recap: what is ARFID?

ARFID stands for Avoidant/Restrictive Food Intake Disorder. It is a recognised feeding and eating disorder in which avoidant or restrictive eating is associated with one or more significant consequences, such as:

• weight loss, failure to achieve expected weight gain or faltering growth;
• significant nutritional deficiency;
• reliance on oral nutritional supplements or enteral feeding;
• marked interference with psychosocial functioning.^1,2

The restriction characteristic of ARFID is not driven by concerns about body weight or shape in the way seen in eating disorders such as anorexia nervosa or bulimia nervosa.^1,2

ARFID can affect children, young people and adults.

1

Sensory differences around food

For some people, the sensory characteristics of food are an important part of their restricted eating. This can involve:

A sensory experience that is manageable for one person may be uncomfortable, overwhelming or inaccessible to another.

What this can look like

• relying on a relatively small range of foods with predictable sensory characteristics;
• preferring particular brands or preparation methods;
• finding changes in packaging, recipe or presentation difficult;
• avoiding particular textures or food categories;
• preferring foods to remain separate;
• finding mixed or inconsistent textures difficult;
• stopping eating a previously accessible food after it changes unexpectedly;
• finding certain smells or foods nearby difficult even when they are not expected to eat them.

2

Low interest in eating or food

For some people, the main difficulty is low interest in eating or food. Some experience relatively little interest in eating, less noticeable appetite or hunger cues, or become full quickly. Eating may feel effortful, or may be easily displaced by other activities.

What this can look like

• eating relatively small amounts;
• becoming full quickly;
• forgetting to eat;
• benefiting from reminders or external structure around eating;
• losing interest partway through a meal;
• taking a long time to eat;
• finding eating effortful or low priority;
• finding it difficult to eat enough even when familiar and accessible foods are available.

It is important not to assume that everyone experiences hunger or appetite in the same way. For these individuals, the main challenge may be less about food variety and more about getting enough nutrition consistently.

3

Fear of aversive consequences

For some people, eating becomes restricted because of concern about something unpleasant or frightening happening when they eat. This can include fear of:

Sometimes this develops after a specific event, such as choking, vomiting or a painful medical episode. For others, there may be no single identifiable starting point.

What this can look like

• avoiding foods believed to be difficult or risky to swallow;
• relying on softer or more predictable foods;
• eating particularly slowly or cautiously;
• experiencing increasing anxiety before or during eating;
• avoiding eating away from familiar environments;
• reducing intake following illness, vomiting, choking or pain;
• seeking reassurance around the safety of eating.

The presentations can overlap

The three presentations are not mutually exclusive.^1,3–6 A person may experience features of one, two, or all three.

A 2024 UK and Republic of Ireland study examined 319 children and young people aged 5–18 years newly identified with ARFID in paediatric or child and adolescent mental-health services.⁴ The researchers identified four groups:

The combined group was therefore the single largest group in that particular clinical sample, although it did not represent a majority of all participants. Other research has also found substantial overlap between ARFID profiles.⁶

The useful message is not that everyone with ARFID will experience several presentations. It is that overlap is common, and a person does not necessarily fit neatly into one category.

Be careful about assuming why someone’s ARFID developed

It can be tempting to create a simple story about how different aspects of ARFID developed or interact. For example:

These relationships may occur for some individuals, but they should not be assumed.

ARFID is likely to arise through multiple interacting factors, and the pathways may differ between individuals. Research into risk factors and mechanisms is still developing.³

A good assessment therefore explores the person’s individual history and experience rather than trying to fit them into a predetermined explanation.

Where sensory differences are important

• understanding which sensory characteristics are difficult or accessible;
• environmental adaptations;
• increasing predictability where helpful;
• identifying nutritionally useful foods with accessible sensory characteristics;
• food exploration or flexibility work where this is an appropriate and agreed goal.

The aim should not be to make sensory differences disappear. For some people, sensory accommodations may remain an appropriate and useful part of eating.

Where low interest is important

• predictable opportunities to eat;
• reducing reliance on hunger alone to prompt eating where hunger cues are not sufficiently reliable;
• increasing the nutritional value of accessible foods where needed;
• practical reminders or routines;
• making food easier to access;
• reducing the effort associated with eating where possible.

Where fear is important

• understanding exactly what the person is concerned will happen;
• appropriate medical or swallowing assessment where indicated;
• reducing uncertainty;
• psychological support where appropriate;
• carefully planned work around feared foods or eating situations where this forms part of an individual treatment plan.

These are examples rather than fixed treatment prescriptions. Individual assessment determines what is appropriate.

ARFID support is broader than the three presentations

The three profiles help us understand what may be contributing to restriction, but they do not tell us everything we need to know about the person. Assessment may also need to consider:

What about autism, ADHD and other neurodevelopmental differences?

ARFID can occur with or without neurodevelopmental differences. Where autism, ADHD or another neurodevelopmental difference is present, assessment should consider how individual differences in areas such as these may interact with eating:

These differences should not automatically be treated as symptoms that need to be removed. Sometimes the most useful support is an accommodation that makes adequate nutrition, eating or participation more accessible.

At other times, a person may want or need support to increase flexibility, reduce fear or improve nutritional adequacy. These approaches are not necessarily in conflict.

Does identifying a presentation determine treatment?

No.

Understanding the presentation can help inform treatment, but it does not prescribe it.

One of the more developed psychological treatments specifically designed for ARFID is Cognitive Behavioural Therapy for ARFID (CBT-AR).⁵ CBT-AR includes modules addressing sensory sensitivity, low interest in eating or food, and fear of aversive consequences.

Treatment choice should take account of factors including:

A profile helps us understand the person. It should not become a treatment algorithm.

What good support looks like

There is no single intervention or feeding strategy that is appropriate for everyone with ARFID. Depending on individual assessment, support may include:

• comprehensive assessment of eating, nutrition, physical health and relevant contributing factors;
• nutritional support to ensure needs are met, including supplementation where appropriate;
• appropriate accommodations that make eating more accessible;
• support with food range or flexibility where this is an appropriate goal;
• medical investigation or treatment where pain, gastrointestinal symptoms or other physical factors are present;
• feeding or swallowing assessment where these skills are a concern;
• psychological or mental-health support where fear, anxiety or other psychological factors are significant;
• multidisciplinary care where needed.

The aim is not simply to increase the number of foods someone eats or to make their eating appear more typical. Meaningful outcomes may include:

If you would like to understand what is contributing to the eating

Whether you are a parent trying to make sense of your child’s eating or an adult trying to understand your own, identifying the factors contributing to restriction can be useful.

Dr Melissa Bujtor works with children, young people and adults experiencing ARFID and other feeding and eating difficulties. Assessment can include:

Where formal diagnosis requires assessment outside the scope of the clinician involved, this should be undertaken by an appropriately qualified professional or multidisciplinary team. The aim is a clear understanding of the individual and what support is actually needed, rather than simply assigning them to one ARFID category.

When to seek further advice

Seek professional advice where restricted eating is affecting:

Also seek assessment where there is:

• significant or rapid weight loss;
• possible nutritional deficiency;
• increasing restriction or loss of previously accessible foods;
• persistent vomiting or pain associated with eating;
• significant fear around eating;
• difficulty chewing or swallowing;
• coughing or choking during eating or drinking.

A final thought

The three ARFID presentations are useful because they help us move away from describing someone simply as a “fussy eater”, or focusing only on the foods they do not eat.

They encourage a different question: what is making eating difficult for this person?

The purpose of understanding the presentations is not to sort people into types. It is to understand their experience more accurately so that nutritional, medical, practical and therapeutic support can be matched to what they actually need.

Prepared by Dr Melissa Bujtor, HCPC Registered Dietitian, AfN Registered Nutritionist (RNutr) and Paediatric Feeding Specialist, for Dr Melissa Bujtor Specialist Dietetic Practice. This fact sheet provides general educational information and is not a diagnostic tool or a substitute for individual assessment.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5-TR. 5th ed, text rev. Washington, DC: American Psychiatric Association Publishing; 2022.
2. World Health Organization. Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. Geneva: World Health Organization; 2024.
3. Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT. Avoidant/restrictive food intake disorder: a three-dimensional model of neurobiology with implications for etiology and treatment. Curr Psychiatry Rep. 2017;19(8):54. doi:10.1007/s11920-017-0795-5.
4. Sanchez-Cerezo J, Neale J, Julius N, Croudace T, Lynn RM, Hudson LD, Nicholls D. Subtypes of avoidant/restrictive food intake disorder in children and adolescents: a latent class analysis. EClinicalMedicine. 2024;68:102440. doi:10.1016/j.eclinm.2024.102440.
5. Thomas JJ, Eddy KT. Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: children, adolescents, and adults. Cambridge: Cambridge University Press; 2018. doi:10.1017/9781108233170.
6. Huryk KM, Drury CR, Loeb KL. Heterogeneous presentations at admission but similar treatment response across latent profiles of ARFID prototypes in children and adolescents. Eur Eat Disord Rev. 2025. doi:10.1002/erv.70024.
7. Burton-Murray H, Becker KR, Breithaupt L, et al. Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: a proof-of-concept for mechanisms of change and target engagement. Int J Eat Disord. 2024.

Prepared by Dr Melissa Bujtor, HCPC Registered Dietitian, AfN Registered Nutritionist (RNutr) and Paediatric Feeding Specialist, for Dr Melissa Bujtor Specialist Dietetic Practice. This fact sheet provides general educational information and is not a diagnostic tool or a substitute for individual assessment.

About the author

Dr Melissa Bujtor

A HCPC Registered Dietitian and AfN Registered Nutritionist with specialist expertise in paediatric dietetics, feeding development and eating disorders.

Dr Bujtor also holds a British Psychological Society-accredited Master’s degree in Psychology, bringing an understanding of behaviour, cognition and emotional development to her clinical work with children and young people.

She is a published scientist whose work spans research, policy and advocacy, and serves on the Board of Trustees of The Feeding Trust, helping to connect research, policy and clinical practice to improve outcomes for children, young people and families.

Her clinical practice combines evidence-based dietetics with a developmental understanding of feeding — looking beyond what a child eats to understand the factors that may be contributing to their difficulties.