Radcliffe ARFID Workgroup: Toward operationalization of research diagnostic criteria and directions for the field
Open accessAbstract
Objective: Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined. Method: In September 2018, a small multi‐disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM‐5 ARFID diagnostic criteria to guide research in this disorder. Results: By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment. Conclusions: This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.
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Written from the paper’s full text.
TL;DR
The Radcliffe ARFID Workgroup convened a 2-day international, multidisciplinary meeting in September 2018 to propose consensus operationalizations of DSM-5 avoidant/restrictive food intake disorder (ARFID) criterion A and recovery for research use. The paper offers definitions to be tested in existing clinical populations and outlines screening, assessment, pathophysiology, and treatment directions for this heterogeneous disorder.
Key findings
- ARFID eating was characterized by food avoidance and/or restriction involving limited volume and/or variety associated with one or more of: weight loss or faltering growth; nutritional deficiencies; dependence on tube feeding or nutritional supplements; and/or psychosocial impairment.
- For criterion A3, the majority agreed on a research threshold of ≥50% of daily caloric intake via oral supplementation or any tube feeding not required by a concurrent medical condition.
- Proposed recovery criteria included eating from all major food groups regularly (e.g., several days, 2–3 per week), weight no longer in the underweight range, no nutritional deficiencies, no more than one nutritional supplement drink per day, and no longer avoiding or experiencing significant distress in social eating situations.
- The group identified a need for a screening tool with established sensitivity and specificity for ARFID and noted that no well-established treatments exist, with limited randomized clinical trials among patients with pediatric feeding disorders.
Methods
- In September 2018, a small international, multidisciplinary group of experts in feeding and eating disorders convened for a 2-day Radcliffe Institute Exploratory Seminar at Harvard University.
- Attendees included clinical psychologists, psychiatrists, pediatricians, dietitians, a gastroenterologist, an endocrinologist, a speech and language pathologist, and an occupational therapist; 20% came from outside the United States.
- The paper reports discussion-based consensus operationalizations (agreed upon by the majority of attendees) and suggested future directions, rather than presenting original empirical data.
Limitations
- The paper states that due to budgetary constraints there was larger representation from the Boston area, though efforts were made to achieve geographical diversity and 20% of attendees came from outside the United States.
- The paper states that the proposed operationalizations and thresholds all warrant testing and validation in existing clinical populations; future data collection is needed to adjudicate the consensus definition for criterion A3.
- The text makes evident that the recommendations are consensus-based rather than empirically validated, and that no diagnostic or screening measure with established sensitivity and specificity for ARFID was available at the time.
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Claims the paper makes
0 of 11 cited sources checked · 0 supported · 0 flagged
- Premisecitation
Goday and colleagues (2019) proposed new diagnostic criteria for pediatric feeding disorder that overlap substantially with DSM-5 ARFID criteria.
“In fact, Goday and colleagues (2019) recently proposed new diagnostic criteria for ‘pediatric feeding disorder,’ which overlap substantially with DSM-5 ARFID criteria.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Goday et al., 2019
Not checked in the free run.
- Premisecitation
The EDY-Q has a suggested cut-off score for possible ARFID.
“The EDY-Q in particular has a suggested cut-off score for possible ARFID.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Kurz et al., 2015
Not checked in the free run.
- Premisecitation
The feeding disorders community has adopted ARFID less widely than the eating disorders community.
“the feeding disorders community—those treating ‘pediatric feeding disorder’ and adults with developmental and physical disabilities—has adopted it less widely (Goday et al., 2019).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Goday et al., 2019
Not checked in the free run.
- Interpretationreasoning
An individual need not have failure to meet nutritional/energy needs in order to have significant psychosocial interference.
“Although the stem criterion A includes the clause, “as manifested by persistent failure to meet appropriate nutritional and/or energy needs,” an individual need not have failure to meet nutritional/energy needs in order to have significant psychosocial interference.”
Quote in the paperSubstantial claim
- May combine two claims. 4
May combine two claims.
PremisecitationTwo new self-report screening tools include the Eating Disorders in Youth-Questionnaire (EDY-Q) for children and adolescents and the Nine Item ARFID Screen (NIAS) for adults.
“Two new self-report screening tools include Eating Disorders in Youth-Questionnaire (EDY-Q; Kurz, van Dyck, Dremmel, Munsch, & Hilbert, 2015) for children and adolescents and Nine Item ARFID Screen (NIAS; Zickgraf & Ellis, 2018) for adults.”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Kurz et al., 2015
Not checked in the free run.
- cites Zickgraf & Ellis, 2018
Not checked in the free run.
May combine two claims.
PremisecitationThe EDY-Q and NIAS both yield dimensional symptom ratings rather than diagnoses.
“These both yield dimensional symptom ratings rather than diagnoses.”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Kurz et al., 2015
Not checked in the free run.
- cites Zickgraf & Ellis, 2018
Not checked in the free run.
May combine two claims.
PremisecitationAs of yet, there are no well-established treatments for ARFID, with a limited number of randomized clinical trials among patients with pediatric feeding disorders.
“As of yet, there are no well-established treatments for ARFID, with a limited number of randomized clinical trials among patients with pediatric feeding disorders (Sharp et al. 2017).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Sharp et al. 2017
Not checked in the free run.
May combine two claims.
PremisecitationDiagnostic tools available for research include the Eating Disorder Assessment for DSM-5 (EDA-5), the ARFID module of the Eating Disorder Examination (EDE-ARFID), and the Pica, ARFID, Rumination Disorder Interview (PARDI).
“Diagnostic tools that are available for use in research include the Eating Disorder Assessment for DSM-5 (EDA-5; Sysko et al., 2015), the new ARFID module of the Eating Disorder Examination (Schmidt, Kirsten, Hiemisch, Kiess, & Hilbert, in press), and the Pica, ARFID, Rumination Disorder Interview (PARDI) (Bryant-Waugh et al, in press).”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Sysko et al., 2015
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- cites Schmidt et al., in press
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- cites Bryant-Waugh et al, in press
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The paper relies on this without support.
Research on ARFID has proliferated and there is lack of clarity in how ARFID is defined.
“Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated, highlighting lack of clarity in how ARFID is defined.”
The paper relies on this without support.
The boundaries of the ARFID diagnosis and operationalization of the criteria remain imprecise.
“However, five years later, the boundaries of the diagnosis and operationalization of the criteria remain imprecise.”
The paper relies on this without support.
ARFID is phenotypically heterogeneous.
“Furthermore, experts noted that ARFID is phenotypically heterogeneous and these variable presentations may in turn call for variable interventions, only some of which would be multidisciplinary.”
The paper relies on this without support.
Individuals with ARFID often present to settings other than mental health clinics.
“Individuals with ARFID often present to settings other than mental health clinics.”
The paper relies on this without support.
Reliance on laboratory data is not feasible because laboratory data do not always correlate with clinical or dietary findings and assays are costly.
“Reliance on laboratory data may not be feasible given that laboratory data do not necessarily always correlate with either clinical or dietary findings and the cost for many of these assays is high.”
The paper relies on this without support.
Community-based expertise in ARFID is limited.
“Given that community-based expertise in ARFID is limited, it was considered a strength that these competencies can be scaffolded based on existing expertise (e.g., with other eating disorders, anxiety disorders, developmental disorders).”
The paper relies on this without support.
The need for multidisciplinary involvement increases at younger ages and with higher levels of severity and medical complexity.
“The need for multidisciplinary involvement increases at younger ages and with higher levels of severity and medical complexity.”
The paper relies on this without support.
Two sets of criteria to classify the same population would further bifurcate the field.
“Our group had concerns that two sets of criteria to classify the same population would further bifurcate the field.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Bringing together feeding and eating disorders in a single grouping represents an expanded appreciation for the clinical significance of feeding problems during infancy and childhood.
“Bringing together FEDs in a single grouping represents an expanded appreciation for the clinical significance of feeding problems during infancy and childhood [75, 76].”
From Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies (2020) · cites this paper as [76]
In “How do we define ARFID?” (page unavailable), the paper says the revised and expanded ARFID criteria provide a diagnostic home for some patients with childhood feeding disorders who would not have met the earlier DSM-IV diagnosis. It does not say that bringing feeding and eating disorders into a single grouping itself represents an expanded appreciation of the clinical significance of feeding problems in infancy and childhood. (LLM, conf=0.79)
Experimental — accuracy not yet measured
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“Processed foods tend to be nutritionally unbalanced, are typically less satiating, and often have high glycemic loads (Fardet, 2016).”
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“The challenge in differential diagnosis and the need to consider developmental stage and context of feeding when considering ARFID diagnosis has recently been highlighted by the ARFID workgroup (54).”
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“In all cases, in order to meet the DSM-5 criteria for ARFID diagnosis, the A/R eating behavior should result in marked psychosocial impairment and/or medical problems requiring professional, medical attention (e.g., nutritional deficiencies, faltering growth) (APA, 2013; Eddy et al., 2019).”
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“Guidelines for assessing medical severity may need to be revised and adapted with these findings in mind, to adequately assess children and adolescents with ARFID, to improve earlier detection, and to minimize medical complications.”
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“Among older patients, ARFID diagnostic criteria do not directly speak to multidisciplinary assessment; however, at a minimum, expert consensus recommends the involvement of a medical professional and mental health clinician as part of routine evaluation and diagnosis (Eddy et al. 2019).”
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“6,7 That is, the lack of interest in eating seen in ARFID may be connected to the same dysregulation of appetite affecting the lack of appetite reflected in the PAGI-SYM among Gp patients.”
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“A multidisciplinary team is necessary when treating low weight or nutritionally compromised patients with ARFID, although less severe cases may be successfully treated by a single practitioner with expertise in ARFID (Eddy et al., 2019).”
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“…accommodation Avoidant/restrictive food intake disorder (ARFID) is characterized by dietary restrictionsthat are not based on weight or shape concerns but that result in marked interferencein feeding, growth, or psychosocial functioning (American Psychiatric ASSOCIATION, 2013; Eddy et al., 2019).”
BackgroundMethodInfluentialEddy, K. T., & Thomas, J. J. (2019) · International Journal of Eating Disorders · doi:10.1002/eat.23052 · Cited by 15 · see citing works
“Rising to this challenge, Eddy et al. (2019) describe how researchers might specifically operationalize diagnostic criteria for ARFID to ensure that the disorder is characterized similarly across studies and that findings can be appropriately compared.”
BackgroundMethodSelf-citationCara, M. D., Rizzo, C., Corallo, F., Cardile, D., Calabrò, R. S., Quartarone, A., Buda, M., & Cucinotta, F. (2023) · Children · doi:10.3390/children10081297 · Cited by 13 · see citing works
Howard, M., Hembry, P., Rhind, C., Siddall, A., Uddin, M. F., & Bryant‐Waugh, R. (2023) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x22000629 · Cited by 13 · see citing works
“The assessment should include a detailed description of the eating difficulties, exploration of the how the three common drivers may be impacting on the child’s presentation, the impact on a child’s physical health, nutrition, social and emotional development, and family life (Eddy et al., 2019).”
BackgroundInfluentialSelf-citationBertrand, V., Tavolacci, M., Bargiacchi, A., Leblanc, V., Déchelotte, P., Stordeur, C., & Bellaiche, M. M. (2024) · European Eating Disorders Review · doi:10.1002/erv.3063 · Cited by 13 · see citing works
Assessing growth in children and adolescents with Avoidant/Restrictive Food Intake Disorder
Tanner, A. B., & Richmond, T. K. (2024) · Journal of Eating Disorders · doi:10.1186/s40337-024-01034-8 · Cited by 11 · see citing works
“Despite the heterogeneity, faltering growth has been identified as a defining feature of ARFID [13] with pubertal delay and growth retardation established as medical complications of ARFID [14–16].”
BackgroundCucinotta, U., Romano, C., & Dipasquale, V. (2023) · Healthcare · doi:10.3390/healthcare11162245 · Cited by 11 · see citing works
Martin, L. D., Fikree, A., Zárate-López, N., Martinkova, K., Brugaletta, C., Perrin, C., & Philpot, U. (2025) · Neurogastroenterology & Motility · doi:10.1111/nmo.70043 · Cited by 9 · see citing works
“A recent review by the authors who originally described ARFID-S provides suggestions for what could be deemed appropriate diagnostic features for DSM-5 criteria A [6]; however, these include both lenient [4] and strict criteria [1, 5].”
InfluentialHarrison, A. (2021) · Child Care in Practice · doi:10.1080/13575279.2021.1958751 · Cited by 10 · see citing works
“The introduction of ARFID replaced and extended previous age-restricted feeding disorders (Eddy et al., 2019; Sharp & Stubbs, 2019) and also provided a diagnostically distinct, specific disorder for many individuals who may have been previously been labelled with other “catch-all” eating disorder…”
InfluentialJohansson, M., Hermansson, J., Linnsand, P., Gillberg, C., & Nygren, G. (2023) · Frontiers in Child and Adolescent Psychiatry · doi:10.3389/frcha.2023.1179775 · Cited by 9 · see citing works
“Such validity problems have been pointed out previously (59, 79, 80).”
BackgroundJackson, B. N., Turner, L. A. T., Kevany, G. L., & Purdy, S. C. (2021) · Speech Language and Hearing · doi:10.1080/2050571x.2021.1926620 · Cited by 8 · see citing works
“ARFID-specific research is emerging, for example cognitive behavioural therapy for adolescents has some case study support, but there are no wellestablished interventions as yet (Dumont et al., 2019; Eddy et al., 2019).”
BackgroundWhy Is Avoidant-Restrictive Food Intake Disorder Relevant to the Pediatric Gastroenterologist?
Oliveira, S. B. D. C. (2021) · Archives of Pediatrics and Adolescent Medicine · doi:10.1001/jamapediatrics.2020.5784 · Cited by 8 · see citing works
Taking Steps Toward a Consensus on Night Eating Syndrome Diagnostic Criteria
Weissman, R. S., Martin‐Wagar, C. A., Attaway, S. E., Penwell, T., Hogan, A., & Pruscino, I. (2024) · International Journal of Eating Disorders · doi:10.1002/eat.24309 · Cited by 9 · see citing works
Matherne, C. E., Watson, H. J., Schmidt, R., Zhu, L. Y., Pamperin, C., van Tilburg, M. A. L., & Bulik, C. M. (2025) · International Journal of Eating Disorders · doi:10.1002/eat.24386 · Cited by 7 · see citing works
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Self-citationBertrand, V., Dhenin, C., Déchelotte, P., & Faerber, M. (2021) · Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity · doi:10.1007/s40519-021-01315-0 · Cited by 6 · see citing works
Winten, C. G., Strodl, E. S., Kambanis, P. E., ROSS, L. J., & Thomas, J. J. (2026) · International Journal of Eating Disorders · doi:10.1002/eat.70086 · Cited by 5 · see citing works
Self-citationBlomsten, A., Trindade, I. A., Nybacka, S., Melchior, C., Algera, J. P., Weznaver, C. D., Störsrud, S., Törnblom, H., & Simrén, M. (2025) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000003735 · Cited by 4 · see citing works
Parent, M. B., Whitley, K. E., Zafar, U., Zickgraf, H. F., & Sharp, W. G. (2023) · Appetite · doi:10.1016/j.appet.2023.107172 · Cited by 3 · see citing works
Self-citationLambert, D., Willmott, E., & Cryer, J. (2025) · European Eating Disorders Review · doi:10.1002/erv.70003 · Cited by 3 · see citing works
Avoidant/Restrictive Food Intake Disorder (ARFID) in Adults
Todisco, P. (2021) · Springer eBooks · doi:10.1007/978-3-030-81174-7_10 · Cited by 4 · see citing works
Clinical Feeding and Swallowing Evaluation for the School-Based Speech-Language Pathologist
D’Angelo, E. C. (2023) · Language Speech and Hearing Services in Schools · doi:10.1044/2023_lshss-23-00019 · Cited by 5 · see citing works
Kerna, N. A., Pruitt, K. D., Jomsky, B. M., Rodriguez, D., Azi, C. I., Carsrud, N. D. V., Ngwu, D. C., Holets, H. M., Flores, J. V., Chawla, S., et al. (2024) · European Journal of Arts Humanities and Social Sciences · doi:10.59324/ejahss.2024.1(2).08 · Cited by 3 · see citing works
“However, it is essential to note that the diagnostic validity of ARFID and its symptom count are still areas of ongoing research (Eddy et al., 2019; Grubb, 2021; Nitsch, Knopf, Manwaring, & Mehler, 2021).”
BackgroundKarvay, Y. (2025) · European Eating Disorders Review · doi:10.1002/erv.3180 · Cited by 4 · see citing works
Socie, C., Descamps, A., Thouvenin, B., Peigné, C. D. F., Abadie, V., & Ouss, L. (2025) · Archives de Pédiatrie · doi:10.1016/j.arcped.2025.02.001 · Cited by 3 · see citing works
Chishti, A. F., Groh, R. E., Maginot, T. R., et al. (2025) · International Journal of Eating Disorders · doi:10.1002/eat.24449 · Cited by 2 · see citing works
“Reported prevalence of ARFID varies widely from 1.5% to 64% within eating disorder populations, while comorbidity with anxiety and depressive disorders is high (Eddy et al. 2019; Zickgraf et al. 2019; Kambanis et al. 2020).”
InfluentialAvoidant/Restrictive Food Intake Disorder: Comorbidities and Longitudinal Course
Kambanis, P. E., Rozzell‐Voss, K. N., Lawson, E. A., Thomas, J. J., & Eddy, K. T. (2023) · Springer eBooks · doi:10.1007/978-3-030-97416-9_91-1 · Cited by 2 · see citing works
Self-citationCase report: Avoidant/restrictive food intake disorder after tonsillectomy
Ahmed, G. K., Karim, A. A., Khedr, E. M., Elbeh, K., Moheb, A., Abokresha, M. M., & Haridy, N. A. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1351056 · Cited by 2 · see citing works
Oliveira, S. B. D. C., & Kaul, A. (2022) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/mpg.0000000000003431 · Cited by 2 · see citing works
Watts, R., Archibald, T., Hembry, P., Howard, M., Kelly, C., Loomes, R., Markham, L., Moss, H., Munuve, A., Oros, A., et al. (2023) · medRxiv · doi:10.1101/2023.02.12.23285723 · Cited by 3 · see citing works
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Zickgraf, H. F., Murray, H. B., & Rigby, A. (2025) · Psychological Reports · doi:10.1177/00332941251330531 · Cited by 2 · see citing works
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Lukens, C. T., Dempster, R. M., Eddy, K. T., Estrem, H., Menzel, J. E., Noel, R. J., Pederson, J. L., Ramirez, A. L., Romeo, C., Sharp, W. G., et al. (2026) · International Journal of Eating Disorders · doi:10.1002/eat.70101 · Cited by 1 · see citing works
Self-citationAvoidant/Restrictive Food Intake Disorder
Menzel, J. E., & Luo, T. J. (2021) · Springer eBooks · doi:10.1007/978-3-030-67127-3_6 · Cited by 1 · see citing works
Self-citationAvoidant/Restrictive Food Intake Disorder in Children
Shimshoni, Y., & Lebowitz, E. R. (2022) · Springer eBooks · doi:10.1007/978-3-030-67929-3_74-1 · Cited by 1 · see citing works
The Classification of Feeding or Eating Disorders in the ICD-11
Pike, K. M., Claudino, D. A., & Claudino, A. M. (2024) · Springer eBooks · doi:10.1007/978-3-031-46096-8_10 · Cited by 1 · see citing works
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“Symptoms may arise in the context of a general lack of interest in food and food selectivity based on sensory sensitivity and fear of negative consequences of eating related to aversion experiences such as asphyxia or vomiting (Eddy et al., 2019).”
BackgroundAvoidant restrictive food intake disorder (ARFID) in children and adolescents
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Avoidant/restrictive food intake disorder: Features and use of cognitive-behavioral therapy
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Avoidant/Restrictive Food Intake Disorder in Children
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Research Status of Eating Disorders and Their Therapy Abroad
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Avoidant/Restrictive Food Intake Disorder: Comorbidities and Longitudinal Course
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- Authors
- Eddy, K. T., Harshman, S. G., Becker, K. R., Bern, E., Bryant‐Waugh, R., Hilbert, A., Katzman, D. K., Lawson, E. A., Manzo, L. D., Menzel, J., Micali, N., Ornstein, R., Sally, S., Serinsky, S. P., Sharp, W., Stubbs, K., Walsh, B. T., Zickgraf, H., Zucker, N., & Thomas, J. J.
- Affiliations
- Harvard University (US)
- Boston Children's Hospital (US)
- University College London (GB)
- Leipzig University (DE)
- University of Toronto (CA)
- Massachusetts General Hospital (US)
- University of California San Diego (US)
- University of Geneva (CH)
- Pennsylvania State University (US)
- Emory University (US)
- Children's Healthcare of Atlanta (US)
- Columbia University Irving Medical Center (US)
- University of Pennsylvania (US)
- Duke University (US)
- Corresponding author
- Eddy, Kamryn T.
- ORCID
- Venue
- International Journal of Eating Disorders
- Publisher
- Wiley
- Published
- 2019-02-13
- Volume
- 52
- Issue
- 4
- Pages
- 361-366
- ISSN
- 0276-3478 (ISSN-L)
- 1098-108X
- PMC
- PMC6485247
- OpenAlex
- W2913471539
- Semantic Scholar
- 5420d1f648590a515409a9a927b5261a696b51bb
- Cited by
- 100
- References
- 19
- Citations by year
- 2026: 9 · 2025: 16 · 2024: 13 · 2023: 21 · 2022: 6 · 2021: 16 · 2020: 13 · 2019: 6
- FWCI
- 11.97
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- International Journal of Eating Disorders (publishedVersion)
- PubMed (publishedVersion)
- Archive ouverte UNIGE (University of Geneva) (publishedVersion)
- PubMed Central (acceptedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
- Funders
- National Institute of Mental Health (1F32MH118824, 1R01MH108595)
- Radcliffe Institute for Advanced Study, Harvard University
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Keywords
- avoidant/restrictive food intake disorder, DSM-5, food avoidance, dietary restriction, weight loss, failure to thrive, nutritional deficiency, psychosocial impairment, eating disorders, feeding disorders
- MeSH terms
- Feeding and Eating Disorders, Humans, Research Design, Retrospective Studies
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