Danny is a 7-year-old boy brought in to see his pediatrician, Dr. Ellis, by his parents because of “picky eating.” Danny’s parents explain that Danny has “never been a great eater,” always requiring more time to complete his feeding or meals than his two older brothers, and being generally averse to the introduction of new food items, but for the past six months, he has become markedly more challenging to feed, refusing most foods other than white bread and undressed pasta. They report that when presented with other foods, such as vegetables, he will push them off his plate. In the cases where the family is able to get him to eat other items, he will make an expression of distress or tell them that it tastes like broccoli (he has taken to calling all foods of any color, including fruits, vegetables, and even many meats, “broccoli”). Mealtime at the dinner table will often result in his crying, so his parents have begun allowing him to eat at a small table in the corner of the room while the rest of the family eats at the main table. He still drinks water, milk, and apple juice. He will eat jelly on his bread when at school (but not at home).

Danny has been appearing more quiet to his parents, often preferring to play alone rather than with his older brother. His father comments that Danny has also been demanding to wear the same sweater day after day, and they have on occasion seen him taking it on and off repeatedly while he is by himself. He has no other physical symptoms, such as vomiting. His parents do note that a couple of weeks before they first noticed these symptoms, Danny had had a sore throat, which resolved over the course of a few days. His parents were hoping that this was “just a phase” but have become increasingly concerned, especially as they are now getting input from the school that he is crying when other children have birthdays and bring in cupcakes for the class (which he refuses to eat). He also has been complaining of “tummy aches” when over at friends’ houses for playdates, often prompting him to be brought home early.

Dr. Ellis’ examination demonstrates that Danny is a thin, young boy, though energetic and otherwise appearing well. His weight has not increased since his last checkup 5 months prior. His physical examination is otherwise unrevealing. He engages as he typically does with Dr. Ellis—reserved and sometimes noted to be clinging to his mother, but answering questions when asked. He communicates clearly and appears to have an age-appropriate vocabulary. Dr. Ellis is considering a gastroenterology consultation to assess for mechanical issues preventing Danny from eating normally, as well as for any allergies or food intolerance that might be causing him to avoid certain items.

Preferred diagnosis: Avoidant Restrictive Food Intake Disorder (ARFID) .

The most suitable diagnosis in this case is ARFID, a new diagnosis to DSM-5 (a variant under the name feeding disorder of infancy and childhood existed in DSM-IV [see Text box: Spotlight on DSM–5 : ARFID]). ARFID can be diagnosed in children and adults, and it describes a pattern of food avoidance in the absence of body image issues or a wish to lose weight [see Text Box: ARFID: DSM-5 Diagnostic Criteria].

A newly defined diagnosis, little is yet known about the prevalence of ARFID in the general population. Small studies have documented a prevalence of approximately 15 % among children and adolescents presenting to specialized eating disorder treatment programs [2].

It is thought that ARFID typically has an onset in childhood and adolescence, though it can begin later in life. Individuals with ARFID may have a history of always being “picky eaters,” or the onset of food avoidance behavior may present more abruptly. The eating behavior itself may vary. For some individuals, the food avoidance may follow an eating-related event, such as choking on a specific food item (in which case, the disorder begins more as a typical phobia); for others, there may appear to be more of a focus on specific elements of the food that are experienced with disgust or anxiety, such as textural or taste components. For some, the avoidance may seem more arbitrary, such as individuals who refuse all food of a certain color, for example.

Little is known about the underlying biological, psychological, or social determinants of ARFID; at this point, the diagnosis is largely defined phenomenologically.

For a child or adult who is experiencing specific food aversions, the evaluation should first focus on an appropriate medical work-up. For example, if the individual is describing symptoms, or exhibiting signs, of choking or even vomiting, upper gastroenterological disorders of the esophagus or stomach may need to be ruled out. As another example, avoidance of specific food items should raise the possibility of allergic or intolerance issues. In the setting of new signs and symptoms, it would be reasonable to start with a thorough evaluation by a general medical practitioner, with judicious use of invasive testing and interventions where indicated.