Applying the Neurodiversity Paradigm to ARFID
Author: Shira Collings, MS, NCC (she/they)
Just as the Health At Every Size and fat liberation movements do not apply to only certain body sizes or BMI categorizations, the neurodiversity paradigm does not only apply to a select group of psychiatric or neurological diagnoses. Similar to the way that HAES and fat liberation seek to reject the idea that any one body size is “correct” and that other body sizes are inherently pathological, the neurodiversity paradigm rejects the idea that there is one correct way to think, feel, act, and perceive the world, and that other ways of doing so are inherently pathological. As a result, while neurodiversity is most commonly associated with ADHD and autism, the concept applies to any mental health or neurodevelopmental diagnosis within the DSM, or any personality trait or way of being that is considered to diverge from what society views as the correct way for bodyminds to operate.
For this reason, I firmly believe that as neurodiversity affirming eating disorder providers, we need to apply the neurodiversity paradigm to ARFID. The ways people move through and perceive the world involves eating; neurodiversity therefore means that there is no one right or wrong way to eat. Treating ARFID as a disorder inherently in need of treatment implies that it is abnormal and incorrect. Since the way we eat shapes so many aspects of our lives, adopting a pathological view of ARFID may also have the effect of implying that someone’s way of living and being more generally is wrong.
The neurodiversity paradigm is based on the social model of disability, which posits that disability results not from a biological impairment but instead from societal exclusion and inaccessibility; the solution is therefore not just medical care but inclusion and accommodation. As an example, it would not necessarily be disabling to use a wheelchair if every building were wheelchair accessible and if society were accepting of wheelchair users.
This is the case for so many people with ARFID, too. Many FIDers (thanks to Kevin Jarvis for coining this term!) can get their nutritional needs met, have a positive relationship with food, and live fulfilling lives in general with adequate acceptance and accommodation. Accommodations could include consistent access to preferred foods, freely available supplements and food products that can help people consume key nutrients in ways that are comfortable for them, and support with planning meals/snacks that incorporate preferred foods and exclude foods that cause sensory distress. Of course, applying the neurodiversity paradigm to ARFID also means combating stigma against any particular foods or categorization of foods as “healthy” or “unhealthy.” This kind of categorization can make eating inaccessible for FIDers, as it can result in preferred foods being associated with shame and fear.
The Consequences of Pathologizing ARFID
Unfortunately, people with ARFID are all too often severely harmed when we do not apply the neurodiversity paradigm to this condition and instead pathologize it. As an eating disorder therapist, I have worked with quite a few individuals who have been forced to eat foods that cause intense sensory distress by their parents and caregivers, medical providers, and therapists. For a lot of FIDers and neurodivergent folks more generally, sensory distress around food is equivalent to pain, so this can be highly traumatizing. In a lot of cases, FIDers’ preferred foods are those that have consistent, predictable textures and palatable tastes. Foods that do not always have these qualities, such as fruits and vegetables, can be difficult to consume. For FIDers who have been forced to consume fruits and vegetables, this can send the message that these foods are “healthy” and morally good, while foods that are more consistent and predictable (e.g., pre-packaged foods, sweet foods) are “unhealthy” and morally wrong. Many FIDers have even been punished for eating their preferred foods or deprived of access to these. Some medical providers encourage parents to deprive their children with ARFID of any preferred foods, with the assumption that they will eventually eat foods that cause sensory distress when they are hungry enough. This does not always turn out to be true.
In my practice and in my own personal life, I have seen the pathologization of ARFID quickly lead to disordered eating and eating disorders. When people learn to associate the only foods that are accessible to them with shame, anxiety, and being “incorrect,” this can make it very difficult to eat adequately and have a positive relationship with food. Intentional restriction is a common result of this, which can lead to further restriction, restrict binge cycles, and/or compensatory behaviors.
Unfortunately, when FIDers seek eating disorder treatment, they are all too often met with pathologization not only of their intentional restriction but also of their ARFID, leading to re-traumatization and further exacerbating disordered eating. I have worked with so many people who have been pressured to eat foods that cause sensory distress in treatment. Despite eating disorder treatment centers often claiming to believe all foods fit and to take a neutral stance around all foods, this does not typically hold up in practice. Even if eating disorder providers do not explicitly say to a FIDer that they have to eat fruits and vegetables because these are “healthy” or “super foods,” there is often messaging around eating a “variety” of foods or a “balanced diet” that implies that foods causing sensory distress need to be incorporated. Many FIDers with co-occurring eating disorders feel shame around not recovering “correctly,” which can discourage pursuing recovery at all.
Applying the neurodiversity paradigm to ARFID can prevent a lot of these problems. I would hope that as eating disorder providers, we can all agree that having a relationship with food that is free of shame is far more important than whether one eats or does not eat any particular food, or the incorporation or lack thereof of any particular micronutrients. By de-pathologizing ARFID, we can move toward a world in which FIDers do not have to experience shame around their relationship with food.
Some Notes of Clarification
I do want to clarify that this does not mean that people with ARFID should not have access to support or care. ARFID can be extremely challenging - it is especially difficult to navigate in our culture, but even if ableism and diet culture did not exist, I imagine ARFID could still cause distress for some people. People with ARFID deserve support to navigate whatever challenges they are facing. For some, this support may include exposure therapy to new foods with the goal of reducing sensory distress with them and working toward a wider variety of food. This can be beneficial for some people, when freely chosen and carried out in an affirming, collaborative way. What the neurodiversity paradigm argues is that the default approach to ARFID should not assume that it needs to be treated or cured. Rather, it should leave room for each person with ARFID to explore what support looks like to them and what a positive relationship with food looks like based on their individual needs, values, and context.
Additionally, based on the definition of neurodiversity at the beginning of this article, some may wonder whether the neurodiversity paradigm also entails seeing disorders like anorexia and bulimia as normal, natural parts of human diversity, or even being pro anorexia/pro bulimia. I want to clarify that this is not my position, and I believe that the way we approach these disorders (i.e., disorders involving the restriction of food for the purpose of weight loss or from a place of healthism) needs to be radically different from the way we approach ARFID. This is because these disorders are by and large praised, glorified, and encouraged in our society, in particular among fat people. The healthcare system itself literally prescribes eating disorders to so many people in larger bodies, in the form of extreme diet and exercise prescriptions, weight loss drugs, and bariatric surgery. When we consider that the neurodiversity paradigm means de-pathologizing those traits and conditions that diverge from what society deems the “normal” or “correct” way of being, and that being restrictive with food and pursuing weight loss is precisely what society considers to be the “normal” and “correct” way to eat, it follows that the neurodiversity paradigm is not quite relevant (at least, not in the same way as ARFID) to disorders like anorexia and bulimia. In a lot of ways, I think we can consider recovery from these disorders - i.e., not restricting or pursuing weight loss - to be more of a form of neurodivergence than the disorders themselves. Much of our society would indeed consider the refusal to restrict or pursue weight loss to be “crazy” or a sign of a mental deficit. When I was in graduate school for mental health counseling, we were assigned case studies of patients in larger bodies who refused to lose weight; we were told the correct approach would be to use motivational interviewing to “help” these “noncompliant” patients who were “in denial” develop insight into their “condition” and motivation to lose weight. Because the neurodiversity model rejects the pathologization of those that society considers to diverge from the correct way of being, it could potentially be applied to recovery.
Conclusion
One goal of neurodiversity affirming care is to support people in unmasking, i.e. in being themselves when it is safe to do so and not forcing themselves to conform to neurotypical norms. In the context of ARFID, forcing oneself to conform to a neurotypical definition of a healthy relationship with food could be considered a way of masking. When we pathologize ARFID and declare that treating its symptoms should be the default approach, we are encouraging the people we work with to mask. I believe that de-pathologizing ARFID and encouraging our clients to unmask around food is a simple yet powerful way to advance disability justice and fight for collective liberation.
Author: Shira Collings, MS, NCC (she/they)
Shira is a pre-licensed counselor in the Philadelphia. She primarily works with people with eating disorders, disordered eating, body image distress, and those breaking free from diet culture. As a neurodivergent diet culture dropout themself, they are especially passionate about supporting neurodivergent folx in finding freedom with food. Click here to learn more about their services.