What immediate and transition care should we provide for a 4.5‑year‑old child with newly diagnosed Avoidant/Restrictive Food Intake Disorder (ARFID), Attention‑Deficit/Hyperactivity Disorder (ADHD), and anxiety, who cannot eat with others or use bathrooms outside the home, while we await relocation from Alaska to a state with better services?

Immediate Care and Transition Planning for Your 4.5-Year-Old with ARFID, ADHD, and Anxiety

Start behavioral parent training immediately—even in Alaska—because this is the first-line treatment for preschool-aged children with ADHD and anxiety, and it will directly address the feeding and bathroom avoidance behaviors while you wait to access specialized ARFID services after your move. 1, 2

What to Do Right Now (Before Moving)

Priority 1: Begin Parent Training in Behavior Management

You can start this immediately without specialized services. Parent training in behavior management (PTBM) teaches you specific techniques to modify and shape your child's behavior at home, and it's the evidence-based first-line treatment for children your son's age with ADHD and anxiety. 1, 3, 2 This approach will help you address:

• The food avoidance and refusal to sit at tables with others
• The bathroom restriction to only your home
• The anxiety-driven behaviors
• The ADHD-related impulsivity and attention challenges

Key point: PTBM works by teaching you to use positive reinforcement, consistent consequences, and behavior-shaping techniques—skills you can learn through books, online resources, or telehealth sessions even in Alaska. 3

Priority 2: Defer Kindergarten—Your Doctor Is Right

Your physician's recommendation to keep him in part-day preschool is medically sound. Children with multiple comorbidities like your son—ARFID, ADHD, and anxiety—require the least restrictive setting that still provides adequate support, and full-day kindergarten with bathroom and eating requirements he cannot meet would set him up for repeated failure experiences. 1

Priority 3: Plan Your Transition Carefully

Transitions are particularly high-risk for children with complex needs like your son. The American Academy of Child and Adolescent Psychiatry emphasizes that during any transition, you must work in partnership with providers to formally assess readiness, determine support methods, and maintain strong collaboration throughout the process. 1

Before you move:

• Request copies of all diagnostic evaluations and treatment notes
• Get written documentation of his diagnoses and functional limitations
• Ask your current provider for referrals to specialists in your new location
• Schedule intake appointments before you arrive if possible

What Services to Pursue After Your Move

The Evidence-Based Treatment Hierarchy

1. Feeding Therapy (Occupational Therapy or Specialized Feeding Program)

ARFID requires specialized intervention, and cognitive-behavioral approaches combined with feeding therapy show the most promise, though the evidence base is still developing. 4 Your son will likely need:

• Exposure therapy delivered by a feeding therapist or occupational therapist trained in ARFID treatment 4
• Gradual desensitization to new foods and eating situations
• Sensory-based interventions if he has texture or sensory aversions 1

Critical caveat: ARFID is highly heterogeneous—some children avoid food due to sensory issues, others due to fear of choking or vomiting, and others due to lack of interest in eating. 5 The specific approach must match your son's particular ARFID presentation.

2. Continue Behavioral Parent Training + Add Behavioral Classroom Interventions

Once he's in a new preschool setting, coordinate with teachers to implement classroom-based behavioral interventions. 1, 3, 2 This includes:

• Visual schedules and transition supports (especially important given his anxiety) 1
• Preferred seating away from triggering stimuli
• Modified expectations around eating and bathroom use initially
• Gradual exposure plans developed collaboratively

3. Play Therapy for Anxiety and Emotional Regulation

Play therapy is appropriate for addressing anxiety and emotional regulation in young children, though it should be integrated with—not replace—behavioral interventions. 6

4. Consider Medication Only If Behavioral Interventions Fail

For preschool-aged children (4-5 years), the American Academy of Pediatrics recommends trying behavioral interventions first, and considering methylphenidate for ADHD only if behavioral approaches don't provide significant improvement and there is moderate-to-severe continued functional impairment. 1, 3, 2

Important safety note: Stimulant medications suppress appetite in most children, which could significantly worsen ARFID. 7 Two case reports describe children with ARFID and ADHD who experienced severe growth restriction after starting stimulants, requiring inpatient eating disorder treatment. 7 If medication becomes necessary, this risk must be carefully monitored.

Educational Planning After Your Move

Pursue either a 504 Plan or Individualized Education Program (IEP) immediately. Educational interventions are a necessary part of any treatment plan for children with ADHD and comorbid conditions. 1, 6, 3 Your son qualifies under "other health impairment" due to his ADHD, and his ARFID and anxiety create additional functional limitations requiring accommodation. 6, 3

Specific accommodations to request:

• Modified bathroom expectations (access to private/preferred bathroom)
• No requirement to eat with peers initially, with gradual exposure plan
• Visual schedules and transition warnings 1
• Sensory breaks as needed
• Shortened school day (part-day program) 1

Understanding the Complexity of Your Son's Presentation

Your son's combination of diagnoses is not uncommon—in fact, it's the rule rather than the exception. Large population studies show that children with ARFID have substantially elevated rates of ADHD (odds ratio 9.4), autism (odds ratio 13.7), anxiety disorders, and other neurodevelopmental conditions. 8, 9 The majority of children with ADHD meet criteria for at least one additional mental disorder. 6

This matters because:

• His conditions interact—anxiety worsens food avoidance, ADHD makes behavioral interventions harder to implement, and all three conditions affect his ability to function in school
• Treatment must address all conditions simultaneously, not sequentially 1, 6
• Untreated ADHD is associated with increased risk for poor mental health, lower educational achievement, and other negative outcomes 1

Common Pitfalls to Avoid

Don't wait until after your move to start behavioral interventions. The positive effects of behavioral therapies persist over time, unlike medication which stops working when discontinued. 1, 2 Every month you implement PTBM now builds skills that will carry forward.

Don't push full-day kindergarten if he's not ready. Placement in overly restrictive or demanding settings increases risk for disconnection, treatment failure, and worsening mental health. 1

Don't treat conditions in isolation. When ADHD, anxiety, and ARFID coexist, addressing only one condition while ignoring the others leads to poor outcomes. 1, 6

Don't start ADHD medication without first establishing feeding therapy and monitoring systems. Given the appetite-suppression effects of stimulants and your son's existing ARFID, this combination requires extremely careful management. 7

Your Action Plan

This month (in Alaska):

• Begin PTBM through books, online resources, or telehealth
• Request all medical records and diagnostic reports
• Research feeding therapy programs and ARFID specialists in your destination state
• Advocate for part-day preschool placement for next year

Upon arrival in your new state:

• Establish care with a pediatrician who understands complex neurodevelopmental presentations
• Enroll in feeding therapy/occupational therapy for ARFID
• Continue PTBM and add classroom behavioral interventions
• Initiate 504 Plan or IEP process
• Consider play therapy for anxiety

Within 3-6 months:

• Reassess whether behavioral interventions alone are sufficient for ADHD symptoms
• If moderate-to-severe functional impairment persists despite behavioral interventions, discuss medication with careful appetite/growth monitoring 1, 3, 7

You've done the hardest part—getting him seen and diagnosed. Now you're building the comprehensive support system he needs, one piece at a time. 1