Rethinking ARFID Treatment: Why Some Approaches Miss the Mark
Avoidant/Restrictive Food Intake Disorder (ARFID) is a diagnosis that’s getting more attention. As new treatments emerge for ARFID, controversy has also come to the forefront. Families are often left feeling confused, overwhelmed, and unsure which treatment path to follow. Some therapies promise results, but they may miss the deeper reasons why a child avoids food. Many therapies fail to create lasting and meaningful change. This piece explores the controversies in ARFID treatment and why a child development lens might offer a better way forward.
What Is ARFID?
ARFID is an eating/ feeding disorder where a child eats so little or avoids so many foods that it affects their health, growth, or daily life. There are three proposed subtypes, which can overlap in any one person:
Sensory: Strong reactions to taste, texture, or smell.
Fear/Aversive: Afraid of choking, vomiting, or stomach pain.
Low Appetite: Seemingly low interest in food.
Why Treatment Is So Controversial
There is no one-size-fits-all approach to ARFID. In fact, there is no gold-standard or evidence-based treatment backed by high quality, long-term studies.
Most research publications are based on case studies or pilot (feasibility) reports.
Many focus on milder presentations of ARFID.
Some studies exclude autistic children.
Most studies emphasize only one ARFID subtype; others do not describe the ARFID subtypes in their sample.
Of the studies that claim positive statistical effects, the clinical relevance is unclear - in other words, we don’t know if the child’s day-to-day life was improved in meaningful ways.
Here are some common approaches, and their challenges:
1. Behavioral Therapy (ABA)
This method treats eating as a behavior to be shaped. Therapists use rewards (like toys or praise) to increase eating and “escape extinction” to reduce refusal. For example, in order for the therapist or parent to remove a spoon from in front of the child’s mouth (called “non-removal of the spoon”), the child has to accept the bite.
Potential Concerns:
Can feel distressing to the child.
May cause the child to gag and even vomit.
May increase anxiety or lead to shutdown.
2. Exposure-Based Therapy (e.g., CBT-ARFID)
This includes repeated exposure to feared or disliked foods, often using food ladders or chains. This means taking a food the child already likes and introducing a similar food with the goal of increasing variety.
Potential Concerns:
May work for the fear subtype (similar to a phobia) of ARFID, but less so for sensory or low appetite types.
Uses exposure hierarchies and hunger/fullness ratings that can feel like pressure, especially for kids with sensory and interoceptive differences.
May prioritize compliance and dietary diversity over emotional safety and autonomy.
3. Family-Based Therapy (FBT-ARFID)
Modeled after anorexia treatment, this approach sees ARFID as an eating disorder as something to fight. Parents are told to take control of meals and push for intake variety and volume, as well as weight gain when needed.
Potential Concerns:
May increase pressure and anxiety.
Does not consider sensory needs or the feeding relationship history.
Assumes urgency even when the child is medically stable.
FBT-ARFID is supported by one small feasibility RCT with 28 participants and a 21% dropout rate. Subtypes were not described, although ARFID symptoms were relatively mild. A larger scale, well-designed study is underway but we do not yet have the results.
4. SPACE-ARFID
SPACE stands for Supportive Parenting for Anxious Childhood Emotions, a parent-based approach to treating anxiety and OCD. SPACE-ARFID views avoidant eating as a response to anxiety. Parents are coached to reduce accommodations (like making separate meals or avoiding food-related conflict) and to respond with calm, supportive language. The child is not the direct target of intervention.
Potential Concerns:
May overlook sensory processing differences.
Assumes anxiety is the primary driver, which may not apply across all ARFID subtypes.
SPACE-ARFID is supported by one small pilot study showing possible improvement in children with mild symptoms, but autistic children and those with oppositional behavior were excluded.
What Current Approaches Might Miss
Many treatments focus on “fixing” the child, and without asking why the child avoids food in the first place. They may overlook:
Sensory factors and interoception
Reasons behind mealtime anxiety
The caregiver-child feeding relationship
When therapy ignores these factors, it can feel like pressure, even if it’s wrapped in praise or play. And pressure often makes things worse.
Are We Overpathologizing?
Some experts worry that ARFID is being overdiagnosed, especially in neurodivergent kids. Just because a child eats differently doesn’t mean they have a disorder. If a child is growing, getting enough nutrients (even through supplements), and not in distress, labeling them with ARFID may do more harm than good.
Labels can:
Make parents feel like something is “wrong” with their child.
Lead to unnecessary or overly intensive treatment.
Create fear and urgency that aren’t always needed and may contribute to avoidant eating.
Instead, we can ask: Is the child safe? Are they doing okay in their own way? Can we support their growth without forcing change? Can we support parents to help the child do their best with eating, even with challenges?
What Families Really Need
Responsive Feeding Therapy (RFT)
This approach focuses on connection, autonomy, and trust. It helps parents create a safe, structured environment where the child can explore food at their own pace.
Benefits:
Supports emotional regulation and interoception (awareness of hunger/fullness).
Builds positive relationships with food and family.
Respects neurodiversity and individual differences.
Most families don’t want a battle at the dinner table. They want peace, connection, and confidence that their child is okay.* Responsive Feeding and Responsive Feeding Therapy offers a way to get there.
*A thorough medical and feeding history, physical exam, and further testing if indicated is required to ensure that any medical, anatomical, or other reason for feeding, nutrition or growth differences are ruled out or addressed.
Responsive Feeding Therapy offers a way to get there.
It helps parents:
Create predictable, low-pressure mealtimes.
Offer a variety of foods without forcing.
Trust their child’s cues and curiosity.
Support emotional regulation and felt safety.
And it helps children:
Feel safe and seen.
Explore food without fear.
Build skills at their own pace.
Develop a positive relationship with eating.
Final Thoughts
ARFID is complex. Treatment should be individualized, too. Instead of rushing to fix or control with treatment protocols with limited evidence, we can slow down, listen, and support (in the majority of cases in the outpatient setting, there is no nutritional or medical emergency). We can trust that most children, even with feeding differences and challenges (and especially when they feel safe and have a supportive feeding environment), will see improvements in their eating in their own time.
As one author wrote: “Food problems have become disconnected from a relational lens, and yet it is human connection that offers us the best fixes we have.”
Let’s bring connection back to the table.
Further Reading
Rowell, K. (2024). Helping Your Child When Mealtimes Are Hard: Loving Support for Anxious Eating, Weight and Nutrition Worries, and Everything in Between.
