PART 2: Is it ARFID? Rethinking Eating Differences Through a Neurodiversity- Affirming Lens.
- Karlien
- Jun 12
- 8 min read
In Part 1, I explored why calling everything "picky eating" can lead us to miss what some children and families are actually experiencing - what ARFID is, how it shows up in real life, and why "wait and see" is rarely the neutral option it sounds like.
Since that post, a few questions have come up.
These are the three questions I want to explore here, and I'll close with how we can
actually support children through it.
For those coming to this topic for the first time, a brief recap:
ARFID - avoidant/restrictive food intake disorder - is a feeding and eating disorder driven
by sensory distress, fear of aversive effects such as choking or vomiting, or a genuinely low
drive to eat. It's not about body image. It can be diagnosed in children and adults at any stage of life. It often overlaps with neurodivergence and can look very different from one person to the next. It can be diagnosed in children and adults at any stage of life.
Certain groups also carry a notably elevated risk: EDFA reports that trans and gender
diverse people are 85 times more likely to experience ARFID.
My child is growing well - can it still be ARFID?
Yes.
To be diagnosed with ARFID, the restriction needs to result in at least one of the following:
significant nutritional deficiency, or dependence on oral nutritional supplements or enteral (tube) feeding
marked interference with psychosocial functioning
low weight or faltering growth
Weight loss or growth faltering is therefore one possible outcome for ARFID, not a
requirement.
Many children and teens with ARFID track steadily along their growth curves, maintain their
weight, or have larger bodies. This is often true for children who can meet their calorie
requirements because their safe food(s) are energy-dense, meaning high in calories.
In addition, even growth charts can mislead us. A child might appear to be growing "fine" on a population growth curve, but if you factor in their genetic potential (like mid-parental
height estimate), or their growth history over time, the picture changes. Some children deviate from their own or expected growth curve without ever dropping below a threshold that would raise a flag. And so, they may be height- or weight-suppressed.
Of course, weight and growth are part of the diagnostic picture, and a clinician should assess a child's growth carefully across the child's lifespan as part of any thorough assessment. But in day-to-day clinical practice, weight change is often not the most obvious sign, and it's not the most reliable one either.
There is also a growing clinical consensus, reflected in 2026 NHS guidance for recognising
eating disorders in children, which moves away from BMI thresholds. Weight is a poor
proxy for malnutrition and medical risk. In eating disorder care, it is well established that children and young people can be severely nutrient-deficient and medically at risk without having lost any weight at all, and in some cases even while actively gaining weight.
When weight appears "fine", families are frequently reassured that there's nothing to worry
about. Meanwhile, eating may be increasingly stressful, limited to a shrinking list of safe
foods, or take over more and more of daily life.
This is one of the many reasons I practise through a weight-neutral lens. Weight is only one
data point, and on its own, it tells us very little about a child's health or their relationship with food. Denying a child support or healthcare based on their size is weight discrimination, and in eating disorder care, it can cause serious harm.
Disordered eating doesn't always look like weight loss, and nutritional risk and malnutrition
aren't always visible from the outside.
Is my child's eating a difference, a difficulty, or a disorder?
This is one of the most important questions I sit with in my work, and one that gets collapsed
far too often into a simple yes-or-no.
Not all selective or sensory-based eating is ARFID. And not all eating that looks "different" from the outside is a problem.
Many neurodivergent children prefer routine, predictability, and familiar sensory experiences
when it comes to food. Eating the same meals, using the same plate, or preferring to eat alone can be forms of regulation and safety rather than pathology.
I, along with many of my like-minded colleagues in the field, find it helpful to think about
this across three categories.
Eating differences are feeding and eating behaviours related to neurotype or sensory
preferences. They may not fit a neurotypical idea of "normal" or "typical" but they don't
cause distress to the child or result in nutritional deficits. In everyday life, this might look like
a child who:
Prefers to eat with their hands* rather than cutlery
Wants to explore food through touch or smell before eating
Requires movement during meals - standing, pacing, bouncing
Uses eating as a form of stimming
Prefers to eat alone rather than in social settings
Relies on familiar, predictable foods to feel safe enough to eat
Needs external cues to remember to eat (as opposed to relying solely on hunger cues)
Prefers to eat while wearing headphones or watching a screen
Through a neurotypical lens, these behaviours are often labelled as "bad manners" or
"problems to fix". For many children and adults, they are adaptive strategies for a
neurodivergent nervous system - ways of regulating, reducing sensory load, and accessing
food.
For parents, this distinction can be deeply relieving. It reframes eating from "what's wrong
with my child?" to "what is helping my child feel safe enough to eat?"
Eating difficulties sit in the middle. These are also feeding and eating behaviours related to
neurotype or sensory preferences, but they result in difficulties for the child - in their mental
health (such as stress or anxiety) or their physical health (such as low iron or poor growth). In
practice, this might look like a child who cannot eat around others, and as a result goes
without food for most of the school day.
Disordered eating or an eating disorder involves feeding and eating behaviours that are not
in line with the child's true preferences, and that cause consistent mental and/or physical
health difficulties over time. This is where the question of ARFID becomes most relevant.
Sometimes a child might want to eat something, but simply cannot.
For clinicians, this asks us to pause and check: are we responding to difference, or to genuine risk and distress?
A question I often return to in my own practice is: if the right accommodations were in place,
would this child be able to meet their nutritional needs? And perhaps more importantly:
Whose goals are we actually working toward, the parents' or the individual's?
This is incredibly nuanced and complex, especially with children. A parent's goals and a child's goals aren't always the same, and whose goals we centre matters. At the same time, we, as caregivers and health professionals, carry real responsibility for a child's well-being. Holding both of those at once is the hard, important part.
It's also a reminder that navigating this well rarely falls to one person. An interdisciplinary
approach, where different perspectives are brought together thoughtfully, tends to serve
children best. And within that, creating genuine space for the child's own voice is essential.
Will my child's eating ever change?
This is the question I get asked most often. And the honest answer is: I don't know.
I'm not trying to be vague, and it's not a cop-out. ARFID is still significantly under-
researched, and under the umbrella of a single diagnosis sits an enormous range of
presentations. If you've met one person with ARFID, you've met one person.
What we do know is that change is possible, and that it often comes from unexpected
directions.
Some children have underlying medical factors that have never been identified. A gut
condition that makes eating genuinely uncomfortable or painful, or a chronic medical
condition, for example, Hypermobile Ehlers-Danlos (hEDS), that affects appetite. When those are finally recognised and managed, eating can start to shift. Not because the ARFID was "fixed" but because the body stopped signalling that food was dangerous.
For others, eating difficulties emerged after a frightening or traumatic experience. When the
nervous system has had the chance to heal - through therapy, time, or the right support -
eating often follows.
And I've heard from many adults with eating difficulties that things shifted meaningfully
when they gained autonomy over their own food. When they could cook for themselves,
access the sensory accommodations they needed, or simply stop being pressured -
something shifted.
Many children and adults expand their eating over time. For others, a dramatically varied
diet may never be the goal, and that's okay. Many adults with ARFID live full, rich, and
happy lives.
What I focus on is meeting nutritional needs safely, and that happens through reducing fear
and nervous system activation, not by pushing through it. Building predictability and trust.
Working with what is already accepted. Moving gradually, and only when a child feels safe
enough to do so. And for some children, that includes oral nutritional supplements. That is
not a last resort or something to be embarrassed about. It is simply one more way of making
sure a child's body has what it needs while everything else is being worked on.
Progress is often slow and non-linear. It might look like eating a safe food more regularly
during the day. Or being okay with a different brand of potato crisps. Being able to sit near a
food without distress. Smelling something without gagging.
These are real steps, even when they don't look dramatic from the outside.
But safety comes before expansion. Always.
So how do we support children and young people with ARFID?
Without guidance, families are often left guessing. Mealtimes can become tense. Parents feel obligated to use shame, guilt, bribery and punishment to "get their child to eat". It doesn't feel good, but at least it feels like they're doing something. And over time, what might have begun as a difference can become more entrenched.
On the other hand, many parents simply "give up". They make peace with their child's
eating and try to be supportive by offering accommodations as far as possible. While that
may cause far less harm than the first scenario, it can also mean a child goes unsupported: still really struggling, and potentially missing important nutrients. Parents are often exhausted too, and some even develop a deep resentment.
Early support isn't about waiting it out or forcing change. It's about reducing stress, maintaining nutrition, and preserving both a child's relationship with food and the parent-child relationship.
I want to be clear about something, because it's easily misread. Practising through a neuro-
affirming, weight-inclusive lens does not mean I think anything goes, or that ARFID doesn't
matter. It's the opposite. ARFID can involve real suffering, for the child and for the family, and where there is distress, risk, or genuine nutritional harm, we have an ethical responsibility to respond. Affirming a child's neurotype isn't an alternative to that responsibility; it's how I try to meet it. Reducing fear, shame, and pressure isn't the soft option - it's the route that tends to reduce suffering rather than add to it.
Neuro-affirming, responsive feeding care is not passive, and it is not the easy route. Creating
safety, adjusting mealtime environments, supporting the nervous system, and working with
what a child currently accepts are active, intentional interventions. They require skill,
consistency, and attunement, even when they don't resemble traditional feeding therapy from the outside.
For clinicians, supporting a child or teenager with ARFID also means being willing to look beyond the presenting behaviour - to explore underlying medical factors with openness and
curiosity, to keep reading and learning, and to examine the ways our own assumptions about
bodies, health, and "normal" eating can get in the way of seeing a child clearly.
In the end, our children deserve care that meets them where they are.
Whatever their eating looks like.
*Eating with utensils is a cultural norm rather than a marker of skill. In many parts of the
world, eating with hands is the standard.
Comments