Picky eating or something more serious? What happens when a child refuses to eat 

SINGAPORE – Like many children, 13-year-old Mathias Perin Bech grew up with an aversion to certain foods.

Tomatoes? Too acidic. Lentils? No go. Zucchini? Absolutely not. Even chocolate was off the table.

Mealtimes, says his mother Estelle Perin, were a nightmare. “I got ‘painted’ with food regularly,” recalls the French national, who is in her 50s and teaches French at Nanyang Technological University.

However, she soon realised that this was not simply a case of picky eating. “It reached a point – I think he was around two years old – where he didn’t want to eat solid food at all. He wanted only the bottle and refused any other kind of food.”

Doctors told her his behaviour was normal at that age, and that it would go away. “But it never did. It was very difficult to make him eat anything. He was gagging, he didn’t want to touch food, didn’t want to see it on his plate. He became anxious if he had to taste it. It was a full circus, to be honest.” 

His phobias could strike suddenly, without warning. One day he was devouring two big bowls of yogurt – the same breakfast he had day in, day out – and the next, he refused to touch it.

“I thought it was too repetitive,” says Mathias, now a Secondary 1 student at International French School. He has lived in Singapore since he was two months old. 

His mother observes: “Once he’s completely withdrawn from the food, it’s very difficult to reintroduce it to him.”

As it turns out, what Mathias has is avoidant/restrictive food intake disorder (ARFID), a condition steadily growing in visibility in Singapore. He was diagnosed at Better Life Psychological Medicine Clinic in Novena when he was eight, vindicating his mother’s longstanding suspicion that his disordered eating was no mere phase. 

“In Mathias’ case, it was not that obvious because he was never really underweight. When we first saw a psychologist, he was able to eat at least five to seven types of food, which is nothing but already much better than other kids, who might be able to eat only three types,” she says. 

It is for these reasons that early identification remains challenging, says Ms Cindy Chan, a senior psychologist at KK Women’s and Children’s Hospital. The diverse ways ARFID presents can make it difficult for families and clinicians to recognise the condition in its early stages. 

“Some individuals with ARFID may also perform well academically and socially, despite having restricted diets. This can create a misconception that the condition is not serious enough for professional intervention, even when nutritional or psychological risks are present.” 

What is ARFID? 

Often confused with picky eating, ARFID is an eating disorder that typically affects children or adolescents. Unlike bulimia or anorexia, it is not fuelled by body image concerns, but a genuine lack of appetite or fear of aversive consequences.  

Dr Natalie Games – a senior clinical psychologist at Alliance Counselling, a private clinic in Bukit Timah – says ARFID shows a more balanced distribution than other eating disorders, with boys equally or more represented in some paediatric settings. 

Most patients present between ages eight and sixteen. At KKH, the median age for an ARFID diagnosis was 11 to 12 from 2022 to 2024, slightly lower than the median age of 13 to 14 for patients with eating disorders in general.

Dr Juliet Tan, a consultant in Adolescent Medicine Service at KKH’s Department of Paediatrics, says: “ARFID tends to have an earlier onset in life compared with other eating disorders, as it does not stem from body image or weight concerns, but rather sensory sensitivities or a fear of potential negative experiences – like choking or vomiting – from eating a particular type or texture of food. Such sensitivities or fears tend to emerge in early childhood, independent of body shape or weight concerns.”

At the same time, Dr Games says that older adolescents and adults are increasingly seeking assessment, often after years of unrecognised difficulties. 

Overall, psychologists have observed a rise in the number of ARFID cases. Ms Henny Tan, principal psychologist at Us Therapy in Winstedt Road, has seen the percentage of referrals for ARFID increase by approximately 33 per cent since 2022. 

Ms Ong Yining, a senior clinical psychologist at Better Life Psychological Medicine Clinic, has observed a similar climb over the last five years. “In specialised eating disorder services, it’s gone from being a rare mention to a more regular part of our caseload. In the 2010s, we might see maybe one or two clear ARFID cases a year.” 

By 2022, KKH was seeing 10 new cases of ARFID. That number rose to 16 in 2023, before dipping to five in 2024. 

However, this does not necessarily mean that ARFID is becoming more prevalent. “It’s more likely our awareness and recognition of it has improved,” says Ms Ong. 

“Before 2013, these patients often slipped through the cracks. They might have been labelled as extremely picky eaters, or their struggles were misdiagnosed as anxiety or obsessive compulsive disorder. With ARFID being officially recognised as a diagnosis, medical professionals now have a clearer framework to understand what we’re seeing, which leads to more appropriate referrals.”

ARFID was added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – the American Psychiatric Association’s professional reference book on mental health and brain-related conditions – published in 2013.

In recent years, developmental and sensory screenings have become more accessible in pre-schools and private clinics, notes Mrs Yael Sasson, clinical director at Dynamics Therapy Group, a specialist clinic at Forum The Shopping Mall. She adds that the Covid-19 pandemic, which disrupted routines, increased screen time during meals and heightened general anxiety, may also be responsible for reinforcing avoidance in many children.

Symptoms of ARFID include sensory selectivity, which could mean aversion to specific textures, smells, colours or tastes. These could include the crunchiness of fruit or the appearance of eggs. Even ingredients “hidden” in sauces might prove too overwhelming, Dr Games has observed.

Children might react by gagging, vomiting or throwing a tantrum. Alternatively, they might display a profound disinterest in eating. Delayed or absent chewing skills could also be a sign of ARFID.

Dangers of ARFID

Often, the first step to getting better is getting diagnosed. A diagnosis, in many cases, explains and absolves. 

“When parents don’t understand that this could be a real disorder, there’s a lot of blaming, shaming and wondering what they did wrong. There are a lot of emotions and speculation. Some might accuse the child of trying to upset the parent,” says Mrs Sasson. 

Ms Ong adds that it is especially helpful in situations where there are nutritional or medical risks, or when families are trying to access coordinated care across healthcare, school and mental health systems. 

Ms Anthea Zee, a dietitian at KKH’s Nutrition and Dietetics Department, stresses the importance of getting help early. “Childhood is a critical period for growth, brain development and the establishment of lifelong eating patterns. From a nutritional perspective, prolonged food restriction increases the risk of inadequate energy, protein and micronutrient intake,” she says. 

This could, in turn, impact a child’s growth, delay puberty, weaken bone health and compromise immune function. Micronutrient deficiencies also pose serious problems – iron deficiency, for one thing, could affect cognitive development and immunity, while a lack of B vitamins might affect energy levels. 

Ms Perin recalls: “As a parent, it’s very disturbing to see your child hungry, yet refusing to eat. Mathias was able to skip meals very easily. As a result, there have been a couple of times when he felt very bad the next day at school. He was shaking, he couldn’t walk.”

Mathias remembers feeling exhausted at football practice too. “I’m usually more short of breath than I am hungry,” he says.

According to Mrs Sasson, some families may delay intervention because they have found “workarounds” – offering the child only “safe” foods, for example – or prioritising speech, motor and behavioural concerns first.

Others believe that children will ultimately eat when hungry enough, says Ms Zee, unaware that people with ARFID may tolerate hunger rather than face an “unsafe” food that triggers intense fear and anxiety.  

The longer intervention is delayed, the harder it gets to correct nutritional deficiencies, especially since childhood and adolescence are critical periods of skeletal development. 

“Calcium, vitamin D, protein and overall energy intake during these critical periods have an influence on bone density, which cannot be fully recovered in adulthood. Delayed intervention in ARFID can result in suboptimal peak bone mass, increasing long-term risk of fractures and osteoporosis later in life,” she says.

On top of its physical consequences, ARFID can restrict a child’s social life, inadvertently isolating him or her. In Matthias’ case, it makes birthday parties and play dates more onerous. 

“Every time he’s invited to one of these things, he’s anxious about the food, so I have to talk to the parents and say don’t be surprised if he doesn’t eat anything,” Ms Perin says. 

Do his friends know about his condition? “Well, I tell them, but then they forget about it. And then they’ll ask me, what’s that? It’s sad there’s no awareness about this compared with other diseases,” says Mathias. 

How to get better

Sometimes though, social pressure helps. A couple of years ago, his friends successfully pressured him into eating a bit of banana.

“I’ll go to my friend’s house and tell them: ‘You have to make me eat this.’ It’s a different kind of pressure from my parents, who tell me to eat something all the time. I feel like I have a duty, like it’s my job to eat the food,” he says. “But it usually doesn’t work for more difficult foods, like cucumber.”

Over the years, Mathias and his mother have tried many things, from hypnotherapy – tapping his body and telling himself “I’m the best friend of vegetables” – to trying to sneak forbidden ingredients into his food. 

“She got me with a lasagna,” he remembers. “There was a bunch of stuff I didn’t like, but I didn’t know, so I ate it a couple of times and liked it.”

His mother says: “When he asked, I told him the truth. There were zucchini and eggplants, all very finely ground, so he couldn’t see it. And the moment he discovered what was inside, he didn’t want to touch it any more.”

Nowadays, he works with Better Life’s Ms Ong to try and experiment with different combinations of foods that mask certain tastes or textures. For instance, she might suggest adding nuts to yogurt to make it crunchy or honey to make it sweet. Something he dislikes is paired with something he enjoys, making these dishes more palatable and ensuring he maintains a balanced diet. 

“The most effective approach is individualised, flexible and often multidisciplinary,” says Ms Ong. 

She uses systematic desensitisation for sensory-based ARFID – a gentle, step-by-step process of getting the patient used to new foods. It might start with placing the food on the table, then urging them to touch, smell and eventually taste it. 

Fear-based ARFID, on the other hand, involves cognitive behavioural therapy to specifically target the catastrophic thoughts about what might happen should they ingest the feared ingredient. 

Ms Tan also uses a multidisciplinary approach, sometimes involving speech therapists to conduct swallowing and feeding evaluations, or occupational therapists to help with sensory processing difficulties. 

At KKH, ARFID is managed through medical monitoring, nutritional guidance and psychological intervention, with approaches tailored to each patient’s specific needs. 

Encouragingly, says Ms Chan, there seems to be an increased understanding among parents and caregivers that ARFID can lead to serious medical, nutritional and developmental complications. This growing awareness has, in turn, propelled many patients to seek proper help. 

However, consistently engaging patients remains an ongoing challenge, with local research indicating high treatment discontinuation rates – possibly driven by residual stigma or questions about treatment effectiveness. 

“ARFID is frequently mischaracterised as simple “picky eating”, leading patients and families to question the necessity of continued treatment once immediate medical concerns appear resolved,” she says. “Patients may also experience feelings of shame when their condition does not align with common perceptions of eating disorders.” 

While the duration of treatment varies based on factors such as severity of symptoms, age and medical risk, it typically spans six to 12 months for children, and six to nine months for adolescents and adults undergoing cognitive behavioural therapy.

Beyond medical treatment, psychologists emphasise the importance of the family in spurring recovery along. “Because meals are so socially and culturally embedded here, involving parents and caregivers in treatment is essential,” says Dr Games. 

Ms Ong likewise coaches parents on how to anchor mealtimes in a calm and supportive way, reducing pressure and anxiety for everyone. 

But for Ms Perin, that does not mean over-indulging Mathias’ phobias. While the family of four has a few safe recipes, she makes it a point to avoid preparing two sets of food. 

“When we cook something he doesn’t like, he has to help himself, because we can’t continue to live with only the few foods he eats,” she says. In such situations, his options are to cook a separate dish for himself or face his fears.

“I don’t want to normalise this. I want him to feel like mealtimes require some effort on his part, because it’s going to be difficult to have a social life if he doesn’t like so many things. I want him to continue seeing the vegetables the family is eating and to have this challenge in front of him that he has to overcome.” 

It is a slow, laborious journey, but Mathias has made progress. He enjoys meat, carbs and dairy – cheese is always good, especially goat cheese. Sometimes, he is even able to stomach a salad or certain vegetables like carrots. 

Zucchini, though? “Forget about it,” Ms Perin says with a laugh.