New Study Sheds Light on Hidden Fears of Children with Avoidant Restrictive Food Intake Disorder 

Your child won’t stop playing video games to come to the dinner table. Or perhaps they talk so much during dinner that they barely eat. Or they’re so fidgety that they can hardly stay seated during a meal. 

Parents may have numerous explanations for their child’s avoidance of food—“How can we compete with video games?” or “They’re just too interested in talking to eat!”—but in some cases, these behaviors could suggest the child is anxious about eating. 

A team of Duke University researchers interviewed dozens of young children with Avoidant Restrictive Food Intake Disorder (ARFID) symptoms to learn how these children experience food-related fears. The study, published on November 8 in the International Journal of Eating Disorders, reveals that children often experience more fear around food than their parents realize, highlighting the need for better understanding and earlier detection of ARFID in children. 

ARFID is an eating disorder characterized by significant weight loss and/or failure to achieve sufficient growth and weight milestones, nutritional deficiencies, need for nutritional supplements to attain adequate dietary quantity or quality, or impairment in psychosocial functioning. (American Psychiatric Association, 2022) Fear is one factor that may drive food avoidance, but the nature and extent of fears in young children with ARFID were not well known. 

Key Findings

The study explored the types and intensity of these fears by interviewing 68 children aged 5 to 10 years old with ARFID symptoms and their parents. Critically, while 91 percent of children reported at least one fear related to food, only 26.5 percent of parents identified similar fears in their children. 

A closer examination revealed that when parents and children disagreed about fears of stomach pain, the child rated the fears more strongly than their parents 96 percent of the time. The pattern of results was similar for the fear of vomiting: 33 of 68 parent-child pairs disagreed on the frequency of the child’s fear. In 88 percent of these cases, the child reported more fear than the parent, and in 58 percent of these cases, parents did not report any fear of vomiting, while the child reported a clinically significant fear of vomiting.

What are we adults missing? The researchers propose several potential hypotheses about what might be happening. “When individuals are experiencing fear, common defensive responses are to fight, flee, or freeze to protect oneself,” explained senior author Nancy Zucker, PhD, a professor of psychiatry and behavioral. “In children, these defensive responses may look different than we expect. Rather than trembling in fear, children may argue, try to change the subject with a funny story, or say, ‘I don't know’—a child's version of fighting, fleeing, or freezing.”

“In children, these defensive responses may look different than we expect. Rather than trembling in fear, children may argue, try to change the subject with a funny story, or say, ‘I don't know’—a child's version of fighting, fleeing, or freezing.”
— Nancy Zucker, PhD

But what are children afraid of? The researchers asked the children to describe their fears or agree or disagree with a list of possible worries. The two top-rated fears were that the food would taste bad or that it would make them gag. Fears related to future experiences of disgust, such as the food looking or smelling disgusting, were rated third and fourth, respectively. 

Implications for Parents and Clinicians

Julia Gianneschi, a research associate in Zucker’s lab and one of the lead authors, highlighted developmental limitations in how children express fears as contributing to problems in early identification: “Young children may not have the vocabulary to express their fears directly,” she said. “They may not label their experience as anxiety and may not think to share it.” 

“Young children may not have the vocabulary to express their fears directly. They may not label their experience as anxiety and may not think to share it.”
— Julia Gianneschi

Kara Washington, a clinical research coordinator in Zucker’s lab and the study’s second lead author, echoed these sentiments, adding, “Children also have creative minds and may have fears we adults haven't even considered. That is why designing developmentally sensitive ways to interview them is so important.” 

The study’s findings underscore the need for clinicians to probe deeper into children’s fears during evaluations for feeding issues. Developing tools that accurately capture these internal experiences will be essential for guiding effective treatment strategies for ARFID in young children.

Next Steps in Research

The team plans to refine their diagnostic tools, including interviews tailored to young children’s cognitive and emotional capacities. “Our goal is to capture and address these early manifestations of ARFID before they become entrenched and lead to more severe health consequences,” said Zucker.

In addition to Zucker, Gianneschi, and Washington, study authors include Julia Nicholas, Ilana Pilato, PhD, Sarah LeMay-Russell, PhD, Alannah M. Rivera-Cancel, Ellen V. Mines, Jalisa E. Jackson, Samuel Marsan, MA, Sage Lachman, MA, Young Kyung Kim, MA, J. Matias Di Martino, PhD, Jane Pendergast, PhD, Katharine L. Loeb, PhD, Debra K. Katzman, MD, Marsha D. Marcus, PhD, Rachel Bryant-Waugh, PhD, and Guillermo Sapiro, PhD.

The study received funding support from the National Institutes of Health and the National Science Foundation. 

Read the study