Abstract
Avoidant Restrictive Food Intake Disorder (ARFID) is increasingly recognised across child, adolescent and adult services, yet clarity regarding occupational therapy’s contribution to ARFID care remains limited. As services evolve in response to rising demand and diagnostic expansion, occupational therapists are frequently positioned within multidisciplinary eating disorder teams without explicit guidance on the competencies required for safe and effective ARFID practice. This ambiguity risks role blurring, professional insecurity and missed opportunities to articulate the distinct role of occupational therapy.
ARFID differs meaningfully from other eating disorders. While anorexia nervosa and bulimia nervosa are typically characterised by weight and shape concerns, ARFID presentations often centre on sensory sensitivities, fear of aversive consequences, limited food repertoire and neurodevelopmental co-occurrence. These features create significant occupational disruption across eating, social participation, family routines, education and employment. Such disruption sits squarely within occupational therapy’s domain. However, eating disorder competency frameworks have largely developed around psychological models targeting body image disturbance and compensatory behaviours. Occupational therapy’s occupation-centred expertise risks being overshadowed within these paradigms.
Competence in this context cannot be reduced to protocol adherence. Evidence from psychotherapy research indicates that therapist competence and treatment integrity are closely associated with improved outcomes (Fairburn and Cooper, 2011). For occupational therapists working in ARFID services, competence must therefore extend beyond generic mental health capability to encompass occupation-focused assessment, sensory-informed intervention, environmental adaptation and collaborative formulation.
Wilcock’s (2006) framework of Doing, Being, Becoming and Belonging offers a valuable structure through which to conceptualise professional competence in ARFID practice.
Doing refers to the observable enactment of professional skill. In ARFID, this includes holistic occupational assessment, dynamic performance analysis of mealtimes, evaluation of sensory processing and implementation of occupation-focused interventions such as graded exposure to food-related tasks, routine development and environmental modification. It also requires clear articulation of how occupational therapy differs from, and complements, dietetic and psychological interventions.
Being reflects therapeutic presence and professional identity. ARFID work often involves high anxiety, entrenched family distress and complex neurodiversity. Occupational therapists must demonstrate reflective capacity, trauma-informed and neuro-affirming approaches, and therapeutic use of self. Research highlights that professional identity clarity is protective against burnout in eating disorder settings (Devery et al., 2018). In psychologically dominated teams, occupational therapists require confidence in their distinct contribution to maintain authenticity and prevent drift into non-occupational roles.
Becoming captures the evolving nature of competence. ARFID remains a relatively recent diagnostic entity (American Psychiatric Association, 2013), and the evidence base is still developing. Ongoing professional development, supervision and engagement in communities of practice are therefore essential. Competence should be understood as dynamic and responsive rather than fixed at qualification.
Belonging situates competence within relational and systemic contexts. Effective ARFID care depends on multidisciplinary collaboration. Occupational therapists must advocate for occupation-centred goals within team formulations and contribute to inclusive, family-centred and community-oriented pathways. This aligns with professional standards emphasising participation, inclusion and occupational justice (Royal College of Occupational Therapists, 2021).
Articulating competence through these four domains does more than provide a checklist of skills. It strengthens occupational therapy’s professional voice within a rapidly evolving clinical landscape. Without explicit frameworks, occupational therapy risks being perceived as ancillary rather than integral to ARFID care. Conversely, a clearly defined competency position enhances interdisciplinary understanding, supports supervision and contributes to workforce sustainability.
As ARFID services continue to expand, the profession has an opportunity to lead. Developing shared competency expectations – grounded in occupation, relational depth and collaborative practice – —will help ensure that occupational therapists remain central to addressing the complex occupational disruption experienced by individuals with ARFID.
The question is not whether occupational therapy has a role in ARFID. It is whether we are sufficiently clear, confident and unified in articulating the competencies that underpin that role.