Terence M. Dovey

Avoidant/Restrictive Food Intake Disorder: An eating disorder on a spectrum with food neophobia.

ABSTRACT

This chapter postulates that food neophobia, picky/fussy eating and avoidant/restrictive food intake disorder (ARFID) sit on the same continuum. All three constructs specifically manifest in early childhood and have, until recently, been considered as separate entities within the literature. Food neophobia, picky/fussy eating and ARFID share many predictive features within their behavioural expression. Moreover, researchers have failed to find suitable and specific measures for any one of these food related behaviours that does not also predict the other two. This chapter covers the similarities and differences between food neophobia, picky/fussy eating and ARFID and offers an applied perspective on the defining characteristics, as well as the limits of these three paediatric feeding phenomena. By understanding food neophobia in the context of an applied problem, the reader can gain deeper insight into the psychological construct. The reader will be guided through the diagnostic criteria of the relatively new disorder of ARFID – weight loss, nutrient deficiency,

dependence on dietary supplementation and interference in psychosocial functioning. This will highlight how diagnosis of ARFID takes place and the difficulties the clinician has in differentiating it from typical developmental food neophobia. Once a full understanding of the diagnostic criteria is achieved, the similarities and differences between the three constructs will be highlighted and an argument advocating a continuum will be offered. In a scenario where constructs are defined by frequency of, rather than differences in, behaviour the only logical conclusion is that food neophobia, picky/fussy eating and ARFID exist on the same continuum.

KEYWORDS

ARFID; Children’s Eating Disorders; Diagnosis; Paediatric Psychology.

INTRODUCTION

Food neophobia, as a developmental milestone, has a known trajectory. Despite a period of difficulty in early childhood, food neophobia is likely to have a low but consistent impact on an individual's food choice and dietary variety by late childhood. Misunderstandings surrounding what constitutes food neophobia can have consequences for children who have eating disorders. Avoidant/restrictive food intake disorder (ARFID) originates in early childhood and is defined by a disturbance in feeding. This disorder manifests as a persistent failure to meet nutritional or energy needs. Once manifest, ARFID is usually stable into adulthood and may explain a large proportion of clients in eating disorder services (Norris et al., 2014). Food neophobia in children is often defined as the reluctance to eat, or the avoidance of, new foods (Birch & Fisher, 1998). As the child ages and becomes more familiar with specific foods they will become less resistant to trying them (Dovey et al., 2008). It is important to note that there is a variation in the severity and duration of the food neophobic phase within the general population. Food neophobia is related to a variety of temperamental constructs and personality traits. Therefore, some children may have a short expression of food neophobia, others may have a prolonged period of rejecting new foods and yet other children may seek out new foods.

The severity of food neophobia is usually determined by the number of separate exposures it takes for the child to accept the food and at least try it. While most children will readily try a food after seven exposures, more severe presentations of food neophobia may require novel foods to be presented many more times before a child will accept it. A child transitioning through their food neophobic stage is not expected to be unwilling to try new foods over time. Older children with more experience of foods will find fewer items novel and therefore will not reject them. Children with ARFID will consistently avoid food.

The stability of food avoidance over time is arguably the principle differentiating factor between food

neophobia and ARFID. Within the context of this chapter, food avoidance will refer to all of the

behaviours and strategies that a child will use to not eat the food presented to them. ARFID is defined

simply as "the avoidance or restriction of food intake manifested by clinically significant failure to meet

requirements for nutrition or insufficient energy intake through oral intake of food" (DSM-V, 2013

p334). Due to food neophobia and ARFID manifesting at similar age ranges, parents of children with

ARFID may be incorrectly told by health professionals that their children’s eating is simply a natural

phase that they will overcome. Non-specialists in the behavioural sciences often confuse the

difference between ARFID and food neophobia. Incorrect advice offered to parents may allow an eating disorder in the child to become more entrenched and undermine early intervention.

Understanding the similarities and differences between food neophobia and ARFID provides a natural applied explanation of the limits of the developmental phenomenon of food neophobia within a disordered eating context of ARFID.

The similarities and differences between food nephobia and ARFID are further complicated by a third similar construct. This third construct arguably rests between food neophobia and ARFID and is referred to as picky or fussy eating. Picky/fussy eating appears to be distinct from food neophobia, but like food neophobia, does not appear to merit clinical psychology attention (Kerzner et al., 2015).

Other allied health professionals may disagree (McCormick & Markowitz, 2013). A recent review article concluded that the most suitable definition for picky/fussy eating was an unwillingness to eat familiar foods or try new foods, severe enough to interfere with daily routines to an extent that is problematic to the parent, child or parent-child relationship (Taylor et al., 2015). Holding to this definition has some merit. However, it is clear with this definition that food neophobia is part of picky/fussy eating, as well as aspects of 'problematic' eating usually attributed to clinically significant feeding problems or ARFID. A secondary and perhaps superseding position would be to suggest that these three concepts exist on a continuum, with developmental food neophobia on one end of the spectrum and ARFID at the other.

Within this chapter, an argument will be offered that food neophobia, picky/fussy eating and ARFID concepts share an aetiological root. These three concepts exist on a continuum similar to other eating-related cognitions such as cognitive restraint (Lyke & Sinella, 2003) and traditional eating disorders of anorexia nervosa (Bulik et al., 2000). While most children will eventually transition through their food neophobic stage, some will not. The relative impact and qualitative differences in the foods that are avoided is likely to define whether the child requires clinical intervention. This chapter will provide the reader with a deconstruction of ARFID within the context of the similarities and differences it shares with food neophobia. At relevant points, picky/fussy eating will also be included to highlight the overlap between these similar psychological constructs. The act of food avoidance shares topographically similar behaviours, however, the underlying function may not be the same.

Function in this context refers to the reason why a child is engaging in a particular behaviour based on the expected consequences they will receive by engaging in a specific behaviour. Topography in the behavioural model refers to the description of what behaviour looks like to an observer. Differences between food neophobia and ARFID define the severity of the disorder and empower the clinician to act. Factors such as nutrient deficiency and its impact on growth will be key determinants of this argument. The final layer of complexity that will be considered within this chapter is that ARFID is a multi-faceted and heterogeneous disorder (Bryant-Waugh et al., 2010). Children that fall into the category of ARFID do so for a variety of reasons. The principle characteristic that all ARFID children share is that they fail to maintain sufficient calories or nutrients to maintain growth. While some factors may be used to differentiate ARFID and food neophobia, it will be argued that based on the current data, differences are difficult to definitively determine through a particular threshold score on a particular measured variable. Without a definitive marker of difference the only conclusion can be that they are similar constructs on the same continuum.

Aetiology

ARFID is a heterogeneous condition (Bryant-Waugh et al., 2010) with four different, but

somewhat interrelated, pathways that can result in diagnosis. The pathways are: 1) Significant weight loss or failure to gain weight to maintain appropriate and expected growth trajectories. 2) Having a habitual diet that results in nutrient deficiency. 3) Dependent on tube feeding or oral nutritional supplements to meet caloric needs. 4) Marked interference with psychosocial functioning. These four criteria are a pragmatic solution to a difficult conundrum that is complicated by food neophobia. It is expected that around 18 months of age a child will being to distrust novel foods and engage in behaviours that look like wilful food refusal. These behaviours will diminish over time. Therefore, the clinician must find a way of diagnosing a child that has an eating disorder and requires intervention while at the same point disregarding the vast majority of children that will naturally overcome their tendency to decline the foods offered to them.

Weight.

There is an expectation that a child should constantly gain weight in the long-term, however, periods of illness are relatively common and may impact on the short-term trajectory of a child's weight status. Therefore, there is a caveat to guide clinicians and researchers within diagnostic manuals concerning what constitutes significant weight loss or failure to gain weight. Explicit instruction is given to the clinician to use their judgement (DSM-V, 2013). The most recent evidence from systematic reviews of the literature has shown that food neophobia does not result in weight loss (Brown et al., 2016). Therefore, as a principle to differentiate food neophobia from ARFID, the observation of weight loss attributed directly to habitual eating behaviour is a marker of an eating disorder rather than of a developmental milestone. Weight loss, in essence, galvanises the clinician into action.

Weight loss is an obvious marker for intervention; however, controversies still remain. The accepted current definition of picky/fussy eating has not filtered into the literature in a consistent manner. Data from studies exploring the impact of picky/fussy eating on weight status has not offered consistent findings. Some authors have reported that picky/fussy children are of a lower weight status (Marchi & Cohen, 1990), while others have suggested they are overweight (Carruth & Skinner, 2000).

Therefore, the clinician's decision about diagnosis based on weight loss cannot be a binary one.

Consideration towards how much, how quickly and other influencing factors that explain a child’s weight loss should inform the decision-making process. Irrespective of the explanation of weight loss for any given child, unless overweight, a child should not lose any additional weight once under the care of a clinician.

Significant weight loss is only the first of four disparate criteria to achieve diagnosis for ARFID.

Not all children with ARFID lose weight. Equally, not all that do lose weight have ARFID. However, we can reasonably conclude based on the data that a child, who loses weight, does so for reasons beyond the impact of food neophobia. Those children that do gain or lose weight corrected against expected population centiles are likely to do so because of picky/fussy eating or ARFID. Those children that are avoidant towards foods high in calories but low in nutrients will likely gain weight.

Equally, children who avoid food that is from certain food groups may have a habitual diet that is low in calories. Thus, the child is at risk of failing to meet growth trajectories or suffer significant weight loss.

Nutrient

The second pathway to ARFID is determined by nutrient deficiency. Effectively, the child consumes foods that meet their caloric needs, but their diet fails to provide for their vitamin and mineral requirements. Using this particular criterion as the basis of diagnosis for ARFID is contentious. Few children meet their nutritional requirements. The majority of the population of developed nations have deficiencies in zinc, iron and vitamin D (Cowin et al., 2007; Kyttala et al., 2010). Therefore, caution must be advised when making direct links between nutrient deficiency with food neophobia, picky/fussy eating and ARFID. While the European population is deficient in zinc, iron and vitamin D, children with picky/fussy eating have been reported to also have lower levels of vitamin E, vitamin C, folate and fibre (Galloway et al., 2005). For ARFID children similar patterns of deficiency have been reported in case studies (Bryant-Waugh, 2013; Dovey et al., 2010). To date, no large scale clinical data has been offered exploring nutrient deficiency. Why this is an important component of ARFID despite being observed as a problem within the general population can be attributed to the different methods of diagnosis for nutrient deficiency used between different populations.

Epidemiological studies typically operate on the logic that self-report data provides insights into

actual nutrient deficiency. However, research has indicated that self-report data on food intake

underestimates actual intake (Schoeller, 2014), food diaries only have a moderate to large correlation

with nutrition levels in the body (Bingham et al., 1997) and the link between food and diet is not

always a simple one (Willett & Sampson, 2012). This technique of using self-report diaries over-

reports nutrient deficiency. Clinical diagnosis relies exclusively on nutrient levels taken from blood

tests. Although it cannot be discounted that children with food neophobia and picky/fussy eating have

nutrient deficiency, the ultimate arbitration of nutrient deficiency is a blood test. Data comparing food

neophobia, picky/fussy eating and ARFID in terms of nutrients in the blood are notably absent in the

literature. Using nutrient profiling for children with ARFID as a marker for intervention is still valid. The

clinical decision is based on an observed reality in a specific individual, while current research only

suggests correlations against proxy markers with known methodological flaws. The definitive

conclusion that can be drawn from the nutritional impact of ARFID is that, like weight, it has the potential to differentiate itself from food neophobia and picky/fussy eating through considering

severity. There is an expectation that deficiency in some vitamins and minerals will be below optimum thresholds within the general population that is unrelated to food avoidance. However, increased levels of deficiency in multiple nutrient markers may be associated with a more restricted dietary variety or pervasive food avoidance.

Dependency on Supplementation

If a child is dependent on artificial meal replacements or tube feeding in order to meet their caloric needs, then it is beyond doubt that they have a problem with their eating behaviour. Children who are food neophobic will not need this form of robust medical intervention for a lack of calorie consumption. In the past, ARFID and the psychologically derived eating disorders in children were referred to by the term non-organic feeding disorder. This differentiated children who avoided or restricted food for psychological reasons from those that require nutritional support for medical reasons (termed organic feeding disorder). Children with such a restricted diet, for either psychological or biological reasons, will be offered meal replacement liquid supplements. In the severest cases, a nasogastric or gastrostomy tube will be fitted to allow nutrients to be pumped directly into the stomach.

The placement of a gastrostomy for purely behavioural reasons is rare. The reason most often given for placing a nasogastric/gastrostomy tube is gastro-oesophageal disease, neuromuscular conditions and growth faltering (Daveluy et al., 2005). However, the process of tube weaning still provides useful insights into food neophobia in children. Tube weaning is the transiting of a child from dependency on tube feeding to full oral eating behaviour that meets their caloric and nutritional needs.

The majority of nasogastric/gastrostomy tubes are placed between one and three years of age (Daveluy et al., 2005), which is during the peak of food neophobia (Addessi et al., 2005). Several possible interpretations can be considered for the increase in placement of tubes during this age range. The first is obvious. Medical complications that interfere in eating behaviour will require invasive procedures in order to maintain growth trajectories. The second is perhaps a little more tenuous. Placing gastrostomy tubes just before and during age ranges typically expected to observe sharp increases in food neophobic behaviours may suggest an implicit understanding that this period is a risk for decreases in variety, calorie and nutrient intake that may result in further weight loss.

These children probably would not survive transitioning through food neophobia at this time. This may suggest that even in children who are medically infirm, food neophobic behaviours are conserved.

Although specific data to this effect is difficult to observe, as these children are often not allowed to consume food, other developmental and biological regulatory processes are still conserved in tube- fed children. For example, tube fed children can energy compensate similar to typically developing children (Kane et al., 2011). Equally, recovery from developmentally appropriate food neophobia appears to be a problem in children with learning disabilities (Marshall et al., 2014) and learning disabilities is a primary predictor of children to remain on long term tube feeding regimes (Trabi et al., 2010). The theoretical basis of this difficulty is that food neophobia is intertwined with the process of learning (Birch et al., 1999). Therefore, children who either cannot experience eating or have a difficulty learning will have an extended and heightened level of entrenched food neophobia. This entrenchment is likely to be a function of duration within the neophobic state without appropriate challenge to their avoidance of new foods.

Several negative effects have been reported following the placing of nasogastric/gastrostomy tubes. These include: elevated parental stress (Enroine et al., 2005), emotional and economic costs (Heyman et al., 2004), and adverse effects on maternal identity (Wilken, 2012). Therefore,

transitioning children from dependence on a tube to oral eating is an important aspect of paediatric psychology. The transitional process is usually termed tube weaning and it is during this time that clinicians have to contend with the entrenched food neophobic tendencies for the first time. Although tube-fed children are likely to have endured traumatic experiences during their medical interventions that leads to a failure to accept foods (Wilken & Bartmann, 2014), the food they are presented with is novel and some of their food avoidance will be due to this novelty. Personal experience with

transitioning children from tube dependency to oral eating, has required some understanding of which

behaviours are functioning through trauma, skill deficit and those that are based on the novelty of the

experience.

Liquid meal replacements are generally reserved for children who are severely malnourished (Lazzerini et al., 2013). From a product designed to save children's lives in geographical regions suffering from periodic famine, liquid meal replacement supplements are increasingly being marketed in nations with more secure food markets and to parents with anxieties about their children's

nutritional status (Lampl et al., 2016). Lampl and co-authors have eloquently argued how the use of liquid meal replacement products during early childhood can naturally undermine the process of exposing children to new foods and parents could become reliant on these products through ease of use and certainty in its nutritional content. The argument continues that typically developing children that use meal replacement products would be less likely to recover from their natural food neophobia and turn to highly hedonic calorie dense low nutrient food items. Although data is not available that the increased use of meal supplements would lead to poorer dietary variety, there is data to support the premise that parents will not sufficiently expose children to novel foods to ensure acceptance (Maier et al., 2007). Therefore, given an easier and well marketed alternative, the use of meal supplements in the general population might not be appropriate.

There is a fine line between those children that may be hindered in their development of dietary variety through liquid meal replacement supplements and those that may need it for optimal growth.

Liquid meal supplements should be prescribed by a professional for children that have lost, or are of a low, weight. This would be the products rightful target market. Difficulties arise in enforcing this process though, as a food supplement is not controlled by the same legalities of prescribed drugs.

Moreover, it has been shown that the use of liquid meal replacements for children with picky eating may be beneficial (Alarcon et al., 2003). The single biggest problem when marketing these products to the general public without prescription is that parents tend to misunderstand what is clinically significant. Many, if not most, parents report their child to be a fussy eater (Coulthard & Harris, 2003), while clinicians place those that are in need of help at a small fraction of the population (Dahl &

Sundelin, 1986). Although there is an argument that some children may have specific micronutrient deficiencies, the use of a calorie dense medium to treat this problem may be misplaced. Children with food neophobia are not underweight; while children with picky/fussy eating and ARFID may be underweight. Furthermore, being underweight is not solely determined by a comparison to population statistics. In any given population we expect variation. Comparatively small statured parents tend to have comparatively small statured children. Therefore, a clinician is required to determine if a liquid meal supplement is an appropriate method of weight gain and growth. A product that is used to improve health, growth and aid in recovery from illness if misunderstood, misapplied and misdiagnosed could further fuel the rise in paediatric obesity.

Marked Interference in Psychosocial Functioning.

Psychosocial functioning within the context of ARFID relates to an inability to participate in normal social activities due to their food avoidance or restriction. This is somewhat difficult to define in the context of children and is perhaps a factor that is better suited to adult sufferers. Children will continue to interact with their family and their parents will continue to care for them irrespective of their feeding difficulties. Therefore, the key determinate of psychosocial functioning in children with ARFID is that their behaviour does not disproportionately impact on their family. Children with ARFID will typically take either much longer or much shorter time periods to eat their meals than other children (Ramsay, Gisel & Boutry, 1993; Reau et al, 1996). Falling into longer or shorter meal durations will depend on a variety of factors. Principally, the behavioural repertoire that the child uses to avoid eating, and the tenacity of the parent in continuing mealtimes in the face of such difficult interactions, will determine how long the meal lasts.

Mealtimes with children with ARFID are characterised by high levels of frustration for the parent

(Garro et al., 2005; Greer et al., 2008) leading to higher levels of parental stress specific to the

mealtime (Martin et al., 2013). Long meal durations is also a potential criteria for fitting feeding tubes

(Sullivan, 1997); although this is usually reserved for children that have neurological impairment or

severe chronic anorexia nervosa. Effectively, a child that takes an inordinate period of time to eat,

characterised as longer than 20-30 minutes (Crist & Napier-Phillips., 2001), will likely interfere with the

harmonious interaction within their family. Children that take beyond an hour could also be having a

significant impact on their own development. Taking a long time to eat a simple meal would mean that

children who spend 3 hours a day eating will not be able to appropriately engage in other aspects of

their psychosocial or academic development. Therefore, careful weighted clinical decision-making is

required to understand what constitutes a mealtime, how long it should last and assess the

importance of this against other essential developmental milestones. Sometimes meal replacement is a necessary stop-gap, which can be returned to at a later date when a higher chance of success or other essential developmental milestones have been met.

It is expected that the vast majority of children will complete their meal within 30 minutes (Reau et al., 1996). It would appear that there is not any data that links high levels of food neophobia and meal duration. It is likely that meal duration in food neophobia will be determined by the novelty of the food presented. Preferred meals will be consumed at a normal rate, while meals comprised of novel foods may take much longer. Therefore, the duration of a meal appears to be a factor solely related to problematic feeding and specifically to ARFID. Beyond meal duration and spending a disproportionate amount of time consuming meals, other factors related to the psychosocial function can be within the domain of the parent-child relationship. Feeding is a primary component of parenting, is one of the first things that parents define their competency on and serves as a process to attune new parents to their child. Attunement in this context is a precursor to attachment (Haft & Slade, 1989). Accurately predicting their child's demands for food and responding appropriately with sufficient milk provides a consistency in the very early relationship that forms a basis for the child's energy security. A

breakdown in this dyadic relationship can serve to disrupt the family dynamic. Indeed, previous formulations of ARFID have suggested that the disorder itself is defined by a breakdown in the parent- child relationship (Chatoor et al., 1998). Typically, this breakdown ultimately culminates in parental force-feeding.

Force-feeding is not typically observed in children with picky/fussy eating or food neophobia, however, researchers have consistently reported similar behaviours in the typically developing population. Within typically developing children with high levels of food neophobia or picky/fussy eating, parents report pressuring their children to eat (Kaar et al., 2016). No behavioural explanation currently exists concerning what force feeding or pressurising children to eat looks like. The difference presumably lies within the physicality of trying to get the child to eat. Pressurising children simply refers to ignoring the child's own self-reported hunger and the parent engages in attempts to get the child to eat (Birch et al., 2003). In contrast, force-feeding typically refers to a variety of strategies that result in the parent physically over-powering the child to consume food. It would appear that children with higher food neophobia will experience pressure or coaxing, while children with ARFID may experience force feeding. Both of these descriptive terms refer to similar constructs differentiated by the magnitude of the parents 'force'. Irrespective, neither construct represents a harmonious parent- child relationship even if it is restricted to just mealtime interactions.

Meal duration and pressure to eat are pertinent factors in both food neophobic children and children with ARFID. While the diagnostic criteria for ARFID seek to differentiate those children that require professional intervention from the general population, it is clear that there are similarities in those children that experience food neophobia compared with those who have ARFID. Therefore, the clinician is consistently checking whether the food avoidance behaviour of their client is transient or stable. Arguably, the ultimate arbitration of the true difference between ARFID and typically

developing rejection of food lies within the duration that the behaviour has been manifest. If the eating problems have been sufficiently stable to be solely responsible for weight loss, observable

deficiencies in essential micronutrients as measured in the child's blood, and/or the child is

maintained by either calorie or vitamin/mineral supplementation they have ARFID. All other aspects of their food avoidance/restriction share an aetiological similarity with food neophobia (see figure 1 for an overview).

Within this section of the chapter we have discussed the differences between ARFID and food neophobia. Even within this section, it is clear there are similarities and high levels of food neophobia may 'look' similar to the presentation of ARFID. The similarities between food neophobia and ARFID extend beyond the diagnosis. Within the next section we will consider the behaviours and features that has been shown to exist in both ARFID and food neophobia. These similarities allude to the final continuum that truly defines how food neophobia and ARFID are related.

INSERT FIGURE 1 ABOUT HERE

Similarities

Factors related to diagnosis of ARFID seek to separate the client from the general population and ascribe to them a term that allows health professionals to intervene. The need to intervene is the sole purpose of the diagnosis and the clinician must be diligent to understand which children will get better with time (i.e. food neophobic) and those that will not (i.e. ARFID). Complexity arises with how picky/fussy eating children should be dealt with. It is not contentious to state that the vast majority of interested researchers and clinicians accept that food neophobia, picky/fussy eating and ARFID share a common aetiology (Bryant-Waugh et al., 2010; Dovey et al., 2009; Smith et al., 2017). This cannot be highlighted further than children with ARFID can be statistically differentiated from the general population by psychometric measures for food neophobia (Dovey et al., 2016); although these are not as accurate as specialist measures. The inability for psychometric measures to distinguish between food neophobia and ARFID is a flaw in current assessment methods (de Lauzon-Guillian et al., 2012);

however, it also highlights just how difficult it is to distinguishing between the two constructs.

Alternatively, the failure of researchers to create sufficient and specific methods to differentiate food neophobia and ARFID may be because the former is a constitute requirement of the latter. After all, a child who avoids all foods will also avoid novel foods. Thus, the topographically defined behaviours may be similar, but the underlying function/reason for the food avoidance may not.

Similarities between food neophobia, picky/fussy eaters and ARFID start with the simple method of the strategies used to avoid eating. Three underlying behaviours define food neophobia – low dietary variety, sensory sensitivity and problematic behaviours during mealtimes (Dovey et al., 2016).

In order to show that food neophobia, picky/fussy eating and ARFID are similar, each of these constituent constructs will be considered.

Low Dietary Variety.

The initial impetus to study food neophobia was to consider why it is difficult to get children to accept fruits and vegetables into their habitual diet (Birch et al., 1987). This research goal was set out even before we had a standardised measure for food neophobia in children (Pliner, 1994). Children that have a diet low in fruit and vegetables will find it difficult to meet their micronutrient needs.

Although it is important for all clinicians and researchers to understand that with the wide introduction of functional and fortified foods, especially of carbohydrate based foods, that it is possible to meet nutritional needs even with a very limited diet. In an environment where core carbohydrates are fortified, a better identifying marker of food avoidance may be dietary variety rather than nutrient deficiency.

Picky/fussy eating and food neophobia are strongly correlated with each other and

deconstruction of genetic and environmental influences suggest a shared aetiology (Smith et al., 2017). Both constructs have been related to lower fruit and vegetable intake and have shared predictors (Galloway et al., 2003). Specific predictors of both food neophobia and picky/fussy eating are family members’ dietary variety and a high sense of time urgency that does not allow for the preparation of meals. ARFID children share a similar problem with dietary variety that may be to the level of brand-specificity (Bryant-Waugh & Piepenstock, 2008).

Within the context of dietary variety, the key determinant of differentiation is stability. Children with high levels of food neophobia will have a more limited dietary variety than their neophilic

peers.

However, food neophobic based low dietary variety is transient and children are likely to increase their consumption of fruits and vegetables in response to exposure (Pliner et al., 1993; Laureati et al., 2014). Recent assessments of pick/fussy eaters suggest both contamination from food neophobia and a similar methodological conundrum highlighted by comparisons with ARFID. Comprehensive

measures of picky/fussy eating tend to report lower prevalence rates within a population (Taylor et al., 2015). Taylor and colleagues showed that single questions (e.g. "is your child a picky eater") appear to return rates of picky eating around 35% of the population, while psychometrically validated

measures tend to report rates closer to 7%. Within their own population based assessment they found rates of around 14%. This 14% observation varied by age in a similar fashion to food neophobia suggesting a contamination of constructs in the sample. Prevalence of ARFID within the population is likely to be much lower than this and current estimates place it at roughly 1% (Dahl & Sundelin, 1986).

1 Neophilic is the opposite of neophobia. Individuals who are neophilic tend to prefer new foods and

experiences and will actively seek these out. Neophilia does not tend to appear until much later in childhood

and early adulthood.

Dietary variety is potentially a sensitive marker of children with higher levels of food neophobia. All children will transition through food neophobia in their early life. Those children that score particularly high on food neophobia scales will have low dietary variety of all. At the upper end of the food neophobic scale

children who are picky/fussy eaters will reside and have an even lower dietary variety. Those children at the upper end of the picky/fussy spectrum are likely to have ARFID and the lowest dietary variety. This explanation provides insight into how a simple food neophobia scale can successfully differentiate children with ARFID from the general population (Dovey et al., 2016).

Effectively, the continuum that these three constructs sit on could be as simple as the number of food items they habitually accept, as well as the generalisation of that acceptance within the same

category of products/foods.

Sensory Sensitivity

Sensory sensitivity is comparatively under-researched. The behaviour is usually described as the child being particularly hypersensitive to sensory stimulation and may result in a variety of difficult behaviours. The behaviours may include over-reactions to any sensory stimulation in any of the sensory domains. Example behaviours that are commonly described as indicative of children who are sensory sensitive are resistance to getting dressed, combing hair, playing with sand, walking on grass or simple social interactions such as hugging (Dunn & Daniels, 2002). The most typical examples are those that are specifically related to touch. The reason for exemplifying sensory sensitivities within the touch domain is that they are related to interaction with the child and so the clinician can determine, through playing with the child, if they are showing signs of this impairment. Although commonly associated with touch, sensitivity may occur in other sensory domains such as sight and sound.

However, in the context of eating behaviour it is within the sensory domains of taste (Dovey et al., 2013) or odour (Dovey et al., 2010) that are most relevant to eating disorders in children. Typically, sensory sensitivity is defined as an overreaction, or offence, resulting in withdrawal from the sensations, either by another person, or by something in their environment, which most would consider inoffensive (Wilbarger, 2000).

Sensory sensitivity in the context of eating is a relatively new addition to the eating behaviour literature; however, it has been well documented as a problem in children with Autistic Spectrum Disorder (Dunn et al., 2002). The food choices of children who are sensory sensitivity are similar to those that are picky/fussy or ARFID. They will often have low dietary variety, an intolerance to textures and engage in a variety of avoidant behaviours (Smith et al., 2005). Interestingly, the

tendency towards sensory sensitivity has also been observed in typically developing children and was a stronger predictor of fruit and vegetable consumption than food neophobia (Coulthard & Blissett, 2009). It must be noted however, sensory sensitivities were strongly associated with food neophobia suggesting that these two factors are intertwined. It is likely that there is a transition period within the sensory processing of food. Developmental differences have been reported between children and adults. While adults will judge willingness to try a novel fruit based on touch, children appear to prefer to base their decisions on how it looks (Dovey et al., 2012). Therefore, it is logical to conclude that at some point in childhood, children learn to prioritise the use of other senses to determine the accuracy of expected tastant.

Sensory sensitivities have been also found in children who are picky/fussy eaters (Nederkoorn et al., 2015), as well as a prominent feature of those children diagnosed with ARFID (Dovey & Martin, 2012). Thus, there is a strong link between the three similar constructs around food avoidance and sensory sensitivity. In a similar manner to dietary variety, the difference between the three constructs of food neophobia, picky/fussy eating and ARFID is likely to be the severity of the insult drawn from the sensory interaction and how impactful it is on food acceptance.

Food Avoidance Behaviours

The prevalence of food avoidance behaviours is difficult to determine. Historically, these

behaviours have simply been referred to as problem behaviours during mealtimes. Examples of these

behaviours are wide ranging and can function through any of the known psychological mechanisms of

attention, escape, tangible or internally motivated events (Piazza et al., 2003a.). However, principally

2 This is a standardised psychometric measure used to differentiate both children (Pliner, 1994) and adults

(Pliner and Hobden, 1992) by how distrustful an individual is to try new foods.

these avoidance behaviours have been attributed to escape processes (Piazza et al., 2003b) and a way of avoiding or restricting food intake. In typically developing community groups within age ranges expected to show peaks in the expression of food neophobia, the questions tend to refer to food refusal (Lewinsohn et al., 2005). The exact type of behaviours employed to refuse food are not, and have not been, reported within typically developing children; however, one study has suggested that these behaviours include spitting out food, hand batting food away, and packing (holding food in the mouth and refusing to swallow it) (Carruth & Skinner, 2000). It is important to consider that the topography of the behaviour any given child expresses is less relevant than what they achieve from it.

Therefore, a variety of behaviours that look very different can be used to achieve the same outcome of avoiding food. The specific behaviour selected by the child is likely to be one that has worked in the past with the individual attempting to make them eat the food presented. Interestingly, the same behaviours have been observed as important food avoidance strategies in children with ARFID (Dovey et al., 2009; Kreipe & Palomaki, 2012 for reviews).

Food avoidance behaviours are typically considered as problematic behaviours because they are barriers to getting a child to accept a wider diet. Novices working in the field of paediatric psychology, and specifically in feeding disorders, often expect that the food avoidant behaviours of children with ARFID are profound. Observations during clinical assessments often do not reveal such

confrontational behaviour between the child and the parent during mealtimes. After all, children with ARFID still wish to maintain their relationship with their primary caregivers and their difficulties are often specific to mealtimes. Effectively, ARFID children have qualitatively different relationships outside of the mealtime compared to within it. This can be shown by parental stress being specific to mealtimes rather than parent stress in general (Martin et al., 2013). Instead of direct confrontation, food avoidance behaviours tend to manifest as less obvious strategies to avoid food.

We have recently presented data that suggests children with ARFID will engage in behaviours such as eating more slowly, show signs of distress/upset, looking away from the table/food, fidgeting, engaging with other objects/activities within the room and spit food out discreetly (Aldridge et al., 2017). The stereotypical perception of a ‘battle of wills’ between the parent and child is rarely observed. The child appears to engage in behaviours that wear their parents down, extend the mealtime and lower their engagement with food. Therefore, the behaviours serve to limit and restrict food intake rather than avoid it altogether.

The use of food avoidance behaviours is observed in typically developing children, picky/fussy eaters and ARFID children. Insights gained from studying food avoidance behaviours suggest that strategies to avoid food are universal. The difference between children with ARFID and those with developmental food neophobia is simply the frequency in which they use them. Children who are engaging in behaviours that avoid eating place them in direct conflict with their parents. This is not a comfortable place for the child to inhabit, as it impacts on the parent-child relationship. Therefore, children who use these food avoidance behaviours do so subtly. It is important to understand that the use of food avoidance behaviours by the child has to be sufficiently motivated whereby the

consequences of their actions through sanctions from the parent are perceived to be less of a punishment than the insult derived from interacting/eating the food offered.

To date, the literature has been extensive on the behavioural elements of food avoidance for ARFID. Consideration of the elusive fourth function of behaviour – internally motivated events – is notably absent. The reason for this absence is that it is difficult to measure internally motivated events, hard to replicate, and is reliant on the parental report of the behaviour on behalf of the child.

This methodological necessity is too distant from the actual cause and makes it unpalatable to the researcher adhering to the edicts of quantitative science. To the lay person these internal events are referred to as emotions. In this context, the principle defining factor that differentiates children with food neophobia from those with ARFID is that food evokes anxiety for those children with the eating disorder.

Defining the True Difference

It cannot be disputed that food neophobia, picky/fussy eating and ARFID share a similar

aetiology. The data generated to date cannot find a single construct or constituent component that

differentiates food neophobia, picky/fussy eating and ARFID. Often arguments for diagnosis or clinical

intervention tend towards impact on the systemic environment of the child or the biological certainty of

weight or nutrition. While, dietary variety, sensory sensitivity and food avoidance behaviours are all set on a continuum, the clinician or interested researcher should consider the motivational operators within the food avoidance. Motivational operators are defined as any factor that increases the reinforcing effects of a stimulus. For example, hunger increases the likelihood that a food will be eaten. Thus, hunger is a motivational operator that increases the reinforcing properties of food in the individual’s environment. Exploring the motivational operation of a behaviour naturally leads the professional away from what the child is doing (i.e. what their behaviour looks like) to why they are doing it (i.e. what they are trying to achieve by engaging in the specific behaviour). For example, a child may be disruptive at mealtime. A food neophobic child will do so to avoid eating a new food. A picky/fussy child may do so because the sensory stimulation of the food is overwhelming/insulting.

Finally, the ARFID child may use the same behaviour because they are anxious about the act of eating or the impact of the food offered. They are all using the same behaviour for different reasons. It is these reasons that will determine the difference between these psychological constructs.

Food neophobia, according to theory, is motivated by distrust and disgust (Pliner, 1994).

Picky/fussy eaters based on the current definitions are motivated by insult primarily rejecting food because it does not meet their rigid scripts about how that food should look (Dovey et al., 2008).

Finally, the overwhelming motivation for food avoidance within ARFID populations is anxiety (Zucker et al., 2015). There is often no specific single cause for anxiety in ARFID. Authors have suggested frequent medical interventions, such as the repeat passing of a nasogastric tube, lead to

posttraumatic stress (Wilken & Bertmann, 2014), an episode of choking (McNally, 1994), or they could simply be highly sensitive that the stimulating properties of food overwhelm the child. Child anxiety appears to be the primary motivating factor in engaging in food avoidance (Farrow & Coulthard, 2012). Although some children with high levels of food neophobia or picky/fussy eating may

eventually develop anxiety within a mealtime, this will fundamentally be different to those that develop ARFID. For the food neophobic or picky/fussy eater the anxiety will originate in the reactions of the parent to their food avoidance. A parent who is particularly draconian or authoritarian in their

approach to disciplining their child following food avoidance will risk associating the negative emotions from this conflict to the mealtime context (Blissett & Haycraft, 2008). In contrast, the ARFID child will be anxious because of the presence of the food itself.

Anxiety may potentially differentiate food neophobia from ARFID; however, this does not alter the process of intervention. Food neophobia, like any phobia, is treated through behavioural exposure based routines (Birch & Marlin, 1982). With the food neophobic primarily avoiding food based on novelty, any process that decreases the novelty and/or increases trust in the food item will have a marked effect on acceptance. For picky/fussy eaters, presentation, texture desensitisation, brand, packaging will all require consideration to improve food acceptance. For these children, their dietary variety is likely to be lower than their peers and so some form of pragmatism may be necessary. As long as their food meets their caloric and nutritional needs, as determined by blood tests, striving for ubiquitous consumption of all fruits and vegetables may be misguided. Indeed, overly focusing on improving diet beyond its nutritional determinants may detract from other developmental milestones.

Finally, the ARFID child will require an extended intervention. Considering methods and interventions to limit and counter anxiety will be paramount. This is especially the case if the child has personally experienced the motivators of their fear, such as a profound choking episode. From a relationship built on trust purposefully built with the child, a clinician can use similar exposure based principles to gradually get their client to accept a food item. This process is protracted and it can take a significantly long time to get the child to accept even a small repertoire of new foods. Exposure to foods is a key determinant between food neophobia, picky/fussy eating and ARFID. The primary differentiator based on intervention is how long, how persistent and the approach to exposure that the adult has to take to ensure acceptance. Figure 2 offers a quick reference summary table of the key similarities and differences between food neophobia, picky/fussy eating and ARFID.

INSERT FIGURE 2 ABOUT HERE

Summary

Food neophobia, picky/fussy eating and AFRID in children share similar characteristics.

Diagnostic criteria used to determine if a child has ARFID is not binary decision-making process. It is

far more subtle. There is no single characteristic that a clinician or researcher can observe that

definitively confirms that a child has an eating disorder. All three psychological constructs that

spontaneously manifest in early life share a common genetic and environmental aetiology. There are some red flag characteristics, such as significant weight loss, nutrient deficiency or reliance on supplementation that can compel a professional to act; but these obvious factors are not always present. Each of the diagnostic criteria for ARFID, as well as the characteristics that define food neophobia, have all been shown to be heightened in all three psychological constructs towards food discussed in this chapter. Every time a researcher or clinician identifies a characteristic within food neophobia, picky/fussy eating or ARFID, similar factors are identified in their sister fields. Moreover, measures for one construct can reliably predict the others. The avoidant behaviours that characterise each of these three constructs are similar.

More-often-than-not the central defining feature is not what behaviours the child engages in, it is the magnitude, voracity and frequency in which they use them during mealtimes. If it is not possible to differentiate children based on what they are doing, and only how often they are doing it, then the only logical conclusion is that food neophobia, picky/fussy eating and ARFID sit on the same continuum.

The data currently available suggests there are limited differences in 'what' the children with food neophobia, picky/fussy or ARFID are doing; however, researchers have yet to offer insights as to why they are doing them. The closest that has been attempted is a functional analysis, which assesses the consequence that most elicits the food avoidance behaviour. With food neophobia, picky/fussy eating and ARFID manifesting early in life and before reliable language development it is not possible to determine exactly why a child engages in food avoidant behaviours. We cannot receive reliable explanations about the motivations through interviewing the child. Therefore, the clinician and researcher are left to reach conclusions about the motivations of the child through observation. Only through careful observation and environmental manipulation can some limited insight be gained. If at any point the child shows anxiety towards a known food, it is likely they will require a carefully

constructed intervention. Even these interventions share similarities. While a food neophobic child will respond to naturalistic exposure through simple observations, picky/fussy or ARFID children will require something more graduated routine based on the underlying reasons for their food avoidance.

Insights gained from paediatric eating disorders offer the practical limitations of food neophobia can be when manifest. A child that becomes increasingly distrustful of food concomitant with

increases in mobility that settles to levels similar to members of their family before the age of 6 is food neophobic. The process is a natural developmental milestone that all children must traverse. The expectation is that food neophobia will not affect the weight of a child, but it is likely to impact on dietary variety and specifically on the consumption of fruit and vegetables. If the child shows signs of sensory sensitivity and is insulted by food or they become anxious upon presentation of a known food, then it is not food neophobia. Alternatively, if the child’s food avoidance behaviours become too invasive to the mealtime that it interferes with the family by increasing meal duration to unsustainable levels it is also not food neophobia. Food neophobia is a protective characteristic that aids children in avoiding harm through avoiding consuming potentially noxious substances. Once the child’s

behaviour ceases to be protective and becomes harmful, it is no longer food neophobia. Such harmful behaviours are expected to be stable into adulthood, will impact on long-term dietary variety, may require calorie supplementation and may require professional intervention. Those children that engage in harmful behaviours have ARFID.

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Figure 1. The five similarities shared by food neophobic, picky/fussy eaters and ARFID children.

Arrows represent increasing levels of the characteristic factor.

Picky/Fussy Eaters

ARFI D

S e n so ry S e ns iti vi tie s S e n so ry S e ns iti vi tie s

Food Neophobic Stage

1

% 14

%

100% of

children

Figure 2. Table to show the similarities and differences between food neophobia, picky/fussy eating and ARFID.

Food Neophobic

Child Picky/Fussy

Eater Child with ARFID Rejects New Foods

Rejects Known Foods

Weight Loss /

Nutrient Deficiency

Dependency on Supplements Sensory Sensitivity

Engages in Food Avoidance Anxiety

Responds to Simple

Exposure