Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment

  • Jennifer J. ThomasEmail author
  • Elizabeth A. Lawson
  • Nadia Micali
  • Madhusmita Misra
  • Thilo Deckersbach
  • Kamryn T. Eddy
Eating Disorders (S Wonderlich and JM Lavender, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Eating Disorders


Purpose of Review

DSM-5 defined avoidant/restrictive food intake disorder (ARFID) as a failure to meet nutritional needs leading to low weight, nutritional deficiency, dependence on supplemental feedings, and/or psychosocial impairment. We summarize what is known about ARFID and introduce a three-dimensional model to inform research.

Recent Findings

Because ARFID prevalence, risk factors, and maintaining mechanisms are not known, prevailing treatment approaches are based on clinical experience rather than data. Furthermore, most ARFID research has focused on children, rather than adolescents or adults. We hypothesize a three-dimensional model wherein neurobiological abnormalities in sensory perception, homeostatic appetite, and negative valence systems underlie the three primary ARFID presentations of sensory sensitivity, lack of interest in eating, and fear of aversive consequences, respectively.


Now that ARFID has been defined, studies investigating risk factors, prevalence, and pathophysiology are needed. Our model suggests testable hypotheses about etiology and highlights cognitive-behavioral therapy as one possible treatment.


Avoidant/restrictive food intake disorder Eating disorder Feeding disorder 



This paper was supported in part by R01MH108595 (mPIs: Thomas, Lawson, Micali).

Compliance with Ethical Standards

Conflict of Interest

Jennifer J. Thomas will receive future royalties from Cambridge University Press for the sale of her forthcoming book Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Dr. Thomas reports grants from National Institute of Mental Health, Hilda and Preston Davis Foundation, and American Psychological Foundation.

Elizabeth A. Lawson is on the Scientific Advisory Board with a financial interest in OXT Therapeutics, Inc. Dr. Lawson reports grants from National Institute of Mental Health and National Institute of Diabetes and Digestive and Kidney Diseases.

Nadia Micali reports grants from National Institute of Mental Health.

Madhusmita Misra reports a grant from Novo-Nordisk and is an advisory board member. Dr. Misra also reports grants from the National Institute of Mental Health.

Thilo Deckersbach reports grants from National Institute of Health.

Kamryn T. Eddy will receive future royalties from Cambridge University Press for the sale of her forthcoming book Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Dr. Eddy reports grants from National Institute of Mental Health, Hilda and Preston Davis Foundation, and American Psychological Foundation.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    American Psychiatric Association. DSM-IV: diagnostic and statistic manual of mental disorders. Washington DC: American Psychiatric Association; 1994.Google Scholar
  2. 2.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Washington DC: American Psychiatric Association; 2013.Google Scholar
  3. 3.
    •• Kurz S, van Dyck Z, Dremmel D, Munsch S, Hilbert A. Early-onset restrictive eating disturbances in primary school boys and girls. Eur Child Adolesc Psychiatry. 2015;24(7):779–85. This questionnaire-based study reported a 3.2% prevalence of ARFID in a primary school setting amongst 8-13 year olds in Switzerland. CrossRefPubMedGoogle Scholar
  4. 4.
    • Ornstein RM, Rosen DS, Mammel KA, Callahan ST, Forman S, Jay MS, et al. Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders. J Adolesc Health. 2013;53(2):303–5. This study of patients presenting to adolescent medicine clinics for eating-disorder evaluation found that 14% met criteria for ARFID. Google Scholar
  5. 5.
    Norris ML, Robinson A, Obeid N, Harrison M, Spettigue W, Henderson K. Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord. 2014;47(5):495–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Fisher MM, Rosen DS, Ornstein RM, Mammel KA, Katzman DK, Rome ES, et al. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a "new disorder" in DSM-5. J Adolesc Health. 2014;55(1):49–52.Google Scholar
  7. 7.
    Nakai Y, Nin K, Noma SI, Teramukai S, Wonderlich SA. Characteristics of avoidant/restrictive food intake disorder in a cohort of adult patients. Eur Eat Disord Rev. 2016;24(6):528–30.CrossRefPubMedGoogle Scholar
  8. 8.
    Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat disord. 2014;2(1):21.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    • Eddy KT, Thomas JJ, Hastings E, Edkins K, Lamont E, Nevins CM, et al. Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. Int J Eat Disord. 2015;48(5):464–70. This retrospective charge review reported a 1.5% prevalence of ARFID among boys and girls ages 8-18 years in a pediatric gastroenterology healthcare network. Google Scholar
  10. 10.
    Pinhas L, Nicholls D, Crosby RD, Morris A, Lynn RM, Madden S. Classification of childhood onset eating disorders: a latent class analysis. Int J Eat Disord. 2017; 50(6):657–64.Google Scholar
  11. 11.
    Dent E. Anorexia of aging and avoidant/restrictive food intake disorder. J Am Med Dir Assoc. 2017;18(5):449–50.Google Scholar
  12. 12.
    Forbush KT, Wildes JE, Pollack LO, Dunbar D, Luo J, Patterson K, et al. Development and validation of the eating pathology symptoms inventory (EPSI). Psychol Assess. 2013;25(3):859–78.Google Scholar
  13. 13.
    Davis Becker KR, Coniglio KA, Thomas JJ, Eddy KT. Reasons for restriction: Avoidant and restrictive food intake disorder versus anorexia nervosa. Poster presentation at the annual international conference on eating disorders meeting, San Francisco, CA; 2016.Google Scholar
  14. 14.
    Kurz S, van Dyck Z, Dremmel D, Munsch S, Hilbert A. Variants of early-onset restrictive eating disturbances in middle childhood. Int J Eat Disord. 2016;49(1):102–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Sysko R, Glasofer DR, Hildebrandt T, Klimek P, Mitchell JE, Berg KC, et al. The eating disorder assessment for DSM-5 (EDA-5): development and validation of a structured interview for feeding and eating disorders. Int J Eat Disord. 2015;48(5):452–63.Google Scholar
  16. 16.
    Bryant-Waugh R, Thomas JJ, Eddy, KT, Micali N, Melhuish L, Cooke L. The development of the Pica, ARFID, and Rumination Disorder Interview (PARDI).Poster presentation at the annual eating disorders research society conference, New York, NY; 2016.Google Scholar
  17. 17.
    Zucker N, Copeland W, Franz L, Carpenter K, Keeling L, Angold A, et al. Psychological and psychosocial impairment in preschoolers with selective eating. Pediatrics. 2015;136(3):e582–90.Google Scholar
  18. 18.
    •• Nakai Y, Nin K, Noma SI, Hamagaki S, Takagi R, Teramukai S, et al. Clinical presentation and outcome of avoidant/restrictive food intake disorder in a Japanese sample. Eat Behav. 2017;24:49–53. This retrospective chart review reported on outcomes of adolescents and adults (ages 15-40) with ARFID over an average duration of 85.2 months. Google Scholar
  19. 19.
    Strandjord SE, Sieke EH, Richmond M, Rome ES. Avoidant/restrictive food intake disorder: illness and hospital course in patients hospitalized for nutritional insufficiency. J Adolesc Health. 2015;57(6):673–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Chandran JJ, Anderson G, Kennedy A, Kohn M, Clarke S. Subacute combined degeneration of the spinal cord in an adolescent male with avoidant/restrictive food intake disorder: a clinical case report. Int J Eat Disord. 2015;48(8):1176–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Tsai K, Singh D, Pinkhasov A. Pudendal nerve entrapment leading to avoidant/restrictive food intake disorder (ARFID): a case report. Int J Eat Disord. 2017;50(1):84–7.CrossRefPubMedGoogle Scholar
  22. 22.
    •• Sharp WG, Volkert VM, Scahill L, McCracken CE, McElhanon B. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: how standard is the standard of care? J Pediatr. 2017;181:116–24. This paper reports a meta-analysis of 11 studies of interventions for children with pediatric feeding disorders. CrossRefPubMedGoogle Scholar
  23. 23.
    Pennell A, Couturier J, Grant C, Johnson N. Severe avoidant/restrictive food intake disorder and coexisting stimulant treated attention deficit hyperactivity disorder. Int J Eat Disord. 2016;49(11):1036–9.CrossRefPubMedGoogle Scholar
  24. 24.
    •• Forman SF, McKenzie N, Hehn R, Monge MC, Kapphahn CJ, Mammel KA, et al. Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative. J Adolesc Health. 2014;55(6):750–6. This paper reports on one-year outcomes of adolescents with ARFID versus AN. Google Scholar
  25. 25.
    Bryant-Waugh R. Avoidant restrictive food intake disorder: an illustrative case example. Int J Eat Disord. 2013;46(5):420–3.CrossRefPubMedGoogle Scholar
  26. 26.
    King LA, Urbach JR, Stewart KE. Illness anxiety and avoidant/restrictive food intake disorder: cognitive-behavioral conceptualization and treatment. Eat Behav. 2015;19:106–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Fitzpatrick KK, Forsberg SE, Colborn D. Family-based therapy for avoidant restrictive food intake disorder: Families facing food neophobias.Family Therapy for Adolescent Eating and Weight Disorders: New Applications, New York: Routledge; 2015; 256–76. Google Scholar
  28. 28.
    Sharp WG, Stubbs KH, Adams H, Wells BM, Lesack RS, Criado KK, et al. Intensive, manual-based intervention for pediatric feeding disorders: results from a randomized pilot trial. J Pediatr Gastroenterol Nutr. 2016;62(4):658–63.Google Scholar
  29. 29.
    Kindermann A, Kneepkens CM, Stok A, van Dijk EM, Engels M, Douwes AC. Discontinuation of tube feeding in young children by hunger provocation. J Pediatr Gastroenterol Nutr. 2008;47(1):87–91.CrossRefPubMedGoogle Scholar
  30. 30.
    Hartdorff CM, Kneepkens CM, Stok-Akerboom AM, van Dijk-Lokkart EM, Engels MA, Kindermann A. Clinical tube weaning supported by hunger provocation in fully-tube-fed children. J Pediatr Gastroenterol Nutr. 2015;60(4):538–43.CrossRefPubMedGoogle Scholar
  31. 31.
    Trabi T, Dunitz-Scheer M, Kratky E, Beckenbach H, Scheer PJ. Inpatient tube weaning in children with long-term feeding tube dependency: a retrospective analysis. Infant Mental Health J. 2010;31(6):664–81.CrossRefGoogle Scholar
  32. 32.
    Clawson EP, Kuchinski KS, Bach R. Use of behavioral interventions and parent education to address feeding difficulties in young children with spastic diplegic cerebral palsy. NeuroRehabilitation. 2007;22(5):397–406.PubMedGoogle Scholar
  33. 33.
    Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. J Pediatr Psychol. 2008;33(6):612–20.CrossRefPubMedGoogle Scholar
  34. 34.
    Byars KC, Burklow KA, Ferguson K, O’Flaherty T, Santoro K, Kaul A. A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feedings. J Pediatr Gastroenterol Nutr. 2003;37(4):473–80.CrossRefPubMedGoogle Scholar
  35. 35.
    Silverman AH, Kirby M, Clifford LM, Fischer E, Berlin KS, Rudolph CD, et al. Nutritional and psychosocial outcomes of gastrostomy tube-dependent children completing an intensive inpatient behavioral treatment program. J Pediatr Gastroenterol Nutr. 2013;57(5):668–72.Google Scholar
  36. 36.
    •• Lukens CT, Silverman AH. Systematic review of psychological interventions for pediatric feeding problems. J Pediatr Psychol. 2014;39(8):903–17. This paper is a qualitative review of 13 studies of treatments of psychological treatments for pediatric feeding disorders. CrossRefPubMedGoogle Scholar
  37. 37.
    Marshall J, Hill RJ, Ware RS, Ziviani J, Dodrill P. Multidisciplinary intervention for childhood feeding difficulties. J Pediatr Gastroenterol Nutr. 2015;60(5):680–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Satter E. Feeding dynamics: helping children to eat well. J Pediatr Health Care. 1995;9(4):178–84.CrossRefPubMedGoogle Scholar
  39. 39.
    Ellis JM, Galloway AT, Webb RM, Martz DM, Farrow CV. Recollections of pressure to eat during childhood, but not picky eating, predict young adult eating behavior. Appetite. 2016;97:58–63.CrossRefPubMedGoogle Scholar
  40. 40.
    Berlin KS, Davies WH, Lobato DJ, Silverman AH. A biopsychosocial model of normative and problematic pediatric feeding. Child Health Care. 2009;38(4):263–82.CrossRefGoogle Scholar
  41. 41.
    Lucarelli J, Pappas D, Welchons L, Augustyn M. Autism Spectrum disorder and avoidant/restrictive food intake disorder. J Dev Behav Pediatr. 2017;38(1):79–80.CrossRefPubMedGoogle Scholar
  42. 42.
    Sant’Anna A, Hammes PS, Porporino M, Martel C, Zygmuntowicz C, Ramsay M. Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program. J Pediatr Gastroenterol Nutr. 2014;59:674–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Thomas JJ, Brigham KS, Sally ST, Hazen EP, Eddy KT.Case records of the Massachusetts General Hospital: An 11-year-old girl with difficulty eating after a choking incident. N Engl J Med. 2017;376(24):2377–86.Google Scholar
  44. 44.
    Nicholls D, Chater R, Lask B. Children into DSM don’t go: a comparison of classification systems for eating disorders in childhood and early adolescence. Int J Eat Disord. 2000;28(3):317–24.CrossRefPubMedGoogle Scholar
  45. 45.
    Pulumo R, Coniglio K, Lawson EA, Micali N, Asanza E, Eddy KT, et al. DSM-5 Presentations of avoidant/restrictive food intake disorder: Are categories mutually exclusive or overlapping? Poster presentation at the Eating Disorders Research Society meeting, New York, NY; 2016.Google Scholar
  46. 46.
    Kauer J, Pelchat ML, Rozin P, Zickgraf HF. Adult picky eating. Phenomenology, taste sensitivity, and psychological correlates. Appetite. 2015;90:219–28.CrossRefPubMedGoogle Scholar
  47. 47.
    Golding J, Steer C, Emmett P, Bartoshuk LM, Horwood J, Smith GD. Associations between the ability to detect a bitter taste, dietary behavior, and growth. Ann N Y Acad Sci. 2009;1170(1):553–7.CrossRefPubMedGoogle Scholar
  48. 48.
    Holsen LM, Lawson EA, Blum J, Ko E, Makris N, Fazeli PK, et al. Food motivation circuitry hypoactivation related to hedonic and nonhedonic aspects of hunger and satiety in women with active anorexia nervosa and weight-restored women with anorexia nervosa. J Psychiatry Neurosci JPN. 2012;37(5):322.Google Scholar
  49. 49.
    Lang PJ, McTeague LM. The anxiety disorder spectrum: fear imagery, physiological reactivity, and differential diagnosis. Anxiety Stress Coping. 2009;22(1):5–25.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Thomas JJ, Eddy KT. Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Children, adolescents, and adults. Cambridge: Cambridge University Press; in preparation.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Jennifer J. Thomas
    • 1
    • 2
    Email author
  • Elizabeth A. Lawson
    • 3
    • 4
  • Nadia Micali
    • 5
    • 6
    • 7
  • Madhusmita Misra
    • 8
    • 9
  • Thilo Deckersbach
    • 2
    • 10
  • Kamryn T. Eddy
    • 1
    • 2
  1. 1.Eating Disorders Clinical and Research ProgramMassachusetts General HospitalBostonUSA
  2. 2.Department of PsychiatryHarvard Medical SchoolBostonUSA
  3. 3.Neuroendocrine UnitMassachusetts General HospitalBostonUSA
  4. 4.Department of MedicineHarvard Medical SchoolBostonUSA
  5. 5.Eating and Weight Disorders Program, Department of PsychiatryIcahn School of Medicine at Mount SinaiNew YorkUSA
  6. 6.Mindich Child Health and Development InstituteIcahn School of Medicine at Mount SinaiNew YorkUSA
  7. 7.Institute of Child HealthUniversity College LondonLondonUK
  8. 8.Pediatric Endocrine UnitMassachusetts General HospitalBostonUSA
  9. 9.Department of PediatricsHarvard Medical SchoolBostonUSA
  10. 10.Divison of NeurotherapeuticsMassachusetts General HospitalBostonUSA

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