Avoidant/restrictive food intake disorder: A diagnosis at the intersection of feeding and eating disorders necessitating subtype differentiation

A US-Based Consensus on Diagnostic Overlap and Distinction for Pediatric Feeding Disorder and Avoidant/Restrictive Food Intake Disorder

OBJECTIVE

As diagnoses covering dysfunctional feeding and eating in pediatrics, avoidant/restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD) contain inherent areas of overlap in their diagnostic criteria. Areas of overlap include criteria regarding nutritional consequences associated with feeding/eating dysfunction and shared emphasis on possible psychosocial impairment associated with restricted food intake. Complicating the differential diagnosis process is a lack of guidance regarding when the two conditions occur independently, co-qualify, and/or transition into the other. Feeding Matters' Research Initiatives Task Force planned and hosted a PFD-ARFID consensus meeting, with the aim of reaching a consensus regarding diagnostic clarity on PFD and ARFID.

METHOD

Criteria for participation focused on US residents who either: (a) served as an author on the ARFID workgroup or PFD consensus papers, or (b) provided community representation via board or committee roles. The consensus process followed three stages: prework, the meeting, and post-work/writing. Twelve participants were present for the meeting, with 14 involved in pre- and post-work/writing.

RESULTS

The final panel included four psychologists representing the ARFID community and seven multidisciplinary members representing PFD's four domains (medical, nutrition, skill, and psychosocial) plus a Zero-to-Three community representative and two representatives from Feeding Matters. Results yielded 10 consensus statements and visuals to support the consensus statements.

DISCUSSION

The consensus process and results underscore an ongoing need to improve diagnostic systems and reinforce calls for strengthening healthcare expertise for both PFD and ARFID. Community-based participatory research is recommended to advance both diagnoses and reduce ambiguity in practice settings.

Predictors of Outcome in Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder

OBJECTIVE

Cognitive-behavioral therapy for avoidant/restrictive food intake disorder (ARFID; CBT-AR) shows promise in improving clinical outcomes in children/adolescents and adults. We aimed to identify predictors of outcomes in CBT-AR. We hypothesized that younger age, non-underweight status, and presence of the fear of aversive consequences profile of ARFID would predict greater likelihood of remission post-treatment, and that presence of the lack of interest in eating/food and sensory sensitivity profiles would predict greater likelihood of persistence post-treatment. We included sex as an exploratory predictor.

METHOD

Individuals (N = 94, ages 10-55 years) were offered 20-30 outpatient sessions of CBT-AR. We collected clinical and demographic data at pre-treatment, and remission status at post-treatment.

RESULTS

Consistent with our hypothesis, presence (versus absence) of the fear profile predicted an almost three-fold increased likelihood of remission. Presence of the sensory profile, lack of interest profile, age, weight status, and sex were not predictors of ARFID outcome.

DISCUSSION

The fear of aversive consequences profile of ARFID may be more amenable to treatment with CBT-AR. This is the first study to identify predictors of treatment outcome following CBT-AR. Randomized controlled trials are needed to confirm these findings and examine moderators.

Empirical Approaches to the Classification of Avoidant/Restrictive Food Intake Disorder

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) is a relatively new formal diagnosis for which empirical classification research (defined here as studies using latent class/latent profile analysis-type methods) is still emerging. Such research focused on ARFID is an important gap to fill given questions about (1) the boundaries between ARFID and phenotypically similar presentations (e.g., eating disorders [EDs] such as anorexia nervosa [AN], and pediatric feeding disorder [PFD]), and (2) within-ARFID heterogeneity. These questions have practical implications, including diagnostic reliability and treatment selection.

METHOD

This forum synthesizes the limited empirical classification literature seeking to quantitatively distinguish ARFID from non-ARFID EDs or from PFD, and/or characterize within-ARFID heterogeneity.

RESULTS

To our knowledge, only five studies in clinical samples have used empirical classification methods to delineate ARFID from non-ARFID EDs and/or characterize within-ARFID heterogeneity; no studies have used such methods to delineate ARFID from PFD. Existing studies are mixed in determining how well ARFID can be distinguished from other EDs (particularly AN), but converge in identifying several potential ARFID subclasses (i.e., sensory sensitivity, low appetite, feared eating-related consequences, and subclass representing a combination of these) with some overlapping features.

DISCUSSION

The existing ARFID empirical classification literature should guide future ARFID classification research priorities (e.g., incorporating mechanistic variables as classification indicators, incorporating longitudinal variables as classification validators) to inform differences between ARFID and other disorders and between ARFID presentations. Dimensional approaches to conceptualizing, studying, and modeling psychopathology (namely, the Hierarchical Taxonomy of Psychopathology [HiTOP] and the Research Domain Criteria [RDoC]) may offer useful insights.

Does multimodal inpatient treatment help some adolescents with severe ARFID?

INTRODUCTION

Avoidant Restrictive Food Intake Disorder (ARFID) is a recently described disorder. Data on inpatient treatment is still scarce, ARFID mainly being an outpatient condition. The purpose of this study is to describe a rare population of adolescents with severe ARFID receiving full-time multimodal inpatient care by examining their clinical characteristics, management, and evolution.

METHODS

We conducted a retrospective study on a series of patients diagnosed with ARFID who were hospitalised from 2005 to 2022. This study was carried out at the Adolescent Medicine department of a University Hospital in Paris, France, specialising in the treatment of eating disorders.

RESULTS

Sixteen adolescents aged 12 to 17 were hospitalised for severe ARFID associated with malnutrition, growth retardation, pubertal delay, and/or psychiatric comorbidities. All but one had body mass indexes less than -2 standard deviations. Mean BMI upon admission was 14,1 [standard deviation=1,8]. They benefited from multimodal treatment plans supported by a multidisciplinary team, including nutritional, somatic and psychiatric transdisciplinary assessment and care, residential care, and family involvement. Length of stay was five months on average, and 50% had achieved normal body mass index at discharge.

CONCLUSIONS

Full-time inpatient care with multimodal and multidisciplinary interventions and tailored management can help restore normal weight for some adolescents. These interventions are aimed at patients with severe ARFID with major complications such as stunted growth and delayed puberty, and/or comorbidities such as depression. Specific subtypes of patients with severe ARFID need to be identified to delineate their characteristics, prognosis, and treatments effective for this group.

Intensive Outpatient Programs for Pediatric Feeding Disorder: A Qualitative Study of Current Challenges and Future Directions

BACKGROUND

Although intensive multidisciplinary interventions (IMIs) provide benefits for patients with pediatric feeding disorders (PFD), access to these programs is limited and challenges faced by the programs remain unclear.

OBJECTIVE

To better understand the barriers faced by existing day programs that provide IMI, disparities in patient care, and areas for improvement to better inform policy and improve access to treatment for PFD.

METHODS

Semi-structured interviews were conducted with a leader of outpatient programs providing IMI in the United States. Data regarding leader's perspectives on disparities in patient care, barriers faced by the intensive multidisciplinary feeding day programs, and future goals and directions for their programming were collected. Afterward, a qualitative content analysis was conducted to consolidate and categorize information related to patient care, access, and barriers faced by day programs and patients with PFD.

RESULTS

Barriers and challenges were identified at the patient, program, and systems levels. Patient-level barriers included familial resources or socioeconomic status, geographic distance from the program site, and difficulty with the time commitment, whereas program-level barriers included limited site personnel and capacity and long wait times. System-level barriers primarily center on insurance, with inconsistent coverage of services and limited payer knowledge about PFD and IMI.

CONCLUSION

IMIs are effective in managing PFD; however, a variety of patient-level, program-level, and systems-level factors serve as barriers for patient access to care and program success. Further research, improved reimbursement, and consensus statements on effective treatments can help improve access to and coverage for care, allowing for the development and sustainability of more programs.

Intensive Multidisciplinary Feeding Day Programs in the United States: A Report Regarding the Treatment Landscape

Intensive multidisciplinary intervention is increasingly recognized as the standard of care for children with complex feeding problems. Much, however, remains unknown about this treatment model. This current qualitative, prospective study sought to identify intensive multidisciplinary day hospital programs operating in the US, describe the treatment approach, and summarize current capacity.

Avoidant Restrictive Food Intake Disorder (ARFID)-Looking beyond the eating disorder lens?

Avoidant Restrictive Food Intake Disorder (ARFID) was first included as a diagnostic category in 2013, and over the past 10 years has been adopted by the international eating disorder community. While greater awareness of these difficulties has increased identification, demand and enabled advocacy for clinical services, the heterogeneous nature of ARFID poses unique challenges for eating disorder clinicians and researchers. This commentary aims to reflect on some of these challenges, focussing specifically on the risk of viewing ARFID through an eating disorder lens. This includes potential biases in the literature as most recent research has been conducted in specialist child and adolescent eating disorder clinic settings, bringing in to question the generalisability of findings to the broad spectrum of individuals affected by ARFID. We also consider whether viewing ARFID predominantly through an eating disorder lens risks us as a field being blinkered to the range of effective skills our multi-disciplinary feeding colleagues may bring. There are opportunities that may come with the eating disorder field navigating treatment pathways for ARFID, including more joined up working with multi-disciplinary colleagues, the ability to transfer skills used in ARFID treatment to individuals with eating disorder presentations, and most notably an opportunity to provide more effective treatment and service pathways for individuals with ARFID and their families. However, these opportunities will only be realised if eating disorder clinicians and researchers step out of their current silos.

Avoidant restrictive food intake disorder: recent advances in neurobiology and treatment

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by persistent insufficient nutritional and/or energy intake. ARFID, before referred to as "selective eating disorder", was introduced recently in the DSM-5 as a replacement for and expansion of the previous diagnosis. Individuals with ARFID may limit food variety and intake due to avoidance based on the sensory characteristics of the food or related to any adverse consequences of eating without the intention of losing weight and concerns of body image. The limited understanding of avoidant and restrictive eating poses challenges to effective treatment and management, impacting directly on the growth and development of children and adolescents. The ARFID neurobiological concept has not yet been clearly defined to clinical practice for nutritionists, thereby hindering screening and impeding the development of treatment recommendations. This narrative review provide useful practical information to consult the pathophysiology, the neurobiology, the clinical features, the assessment and the treatment for healthcare professionals seeking to enhance their clinical knowledge and management of this disorder.

The relationship between food selectivity and stature in pediatric patients with avoidant-restrictive food intake disorder - an electronic medical record review

BACKGROUND

We aimed to characterize stature in pediatric patients with avoidant/restrictive food intake disorder (ARFID), including associations between body size and nutrient intake and height.

METHODS

We conducted a secondary analysis of pre-treatment data from 60 patients diagnosed with ARFID that were collected from the electronic medical record. Anthropometric measurements were converted to age- and sex-specific Z-scores using pediatric CDC growth charts. Spearman correlations were performed to test the relationship between height and weight/BMI Z-scores as well as height Z-score and diet variables.

RESULTS

On average, height (-0.35 ± 1.38), weight (-0.58 ± 1.56), and BMI (-0.56 ± 1.48) Z-scores tended to be lower than what would be expected in a generally healthy pediatric population. Percent of individuals with height, weight, or BMI Z-score < -2.0 was 8%, 20%, and 17%, respectively. BMI (P < 0.05) and weight (P < 0.05) were positively associated with height Z-score. Further, intake of some nutrients (e.g., calcium, vitamin D) correlated positively with height Z-score (all P < 0.05).

CONCLUSIONS

The cross-sectional relationships reported in this study suggest that in children with ARFID, body weight and consumption of bone-augmenting nutrients such as calcium and vitamin D correlated with height. A thorough understanding of the clinical manifestations of malnutrition and longitudinal effects of restrictive eating in patients with ARFID is critical.

Prospective 2-Year Course and Predictors of Outcome in Avoidant/Restrictive Food Intake Disorder

OBJECTIVE

To evaluate the 2-year course and outcomes of full and subthreshold avoidant/restrictive food intake disorder (ARFID) in youth aged 9 to 23 years at baseline using a prospective longitudinal design to characterize the remission and persistence of ARFID, evaluate diagnostic crossover, and identify predictors of outcome. Greater severity in each ARFID profile-sensory sensitivity, fear of aversive consequences, and lack of interest-was hypothesized to predict greater likelihood of illness persistence, controlling for age, sex, body mass index percentile, ARFID treatment status, and baseline diagnosis.

METHOD

Participants (N = 100; age range, 9-23 years; 49% female; 91% White) were followed over 2 years. The Pica, ARFID, and Rumination Disorder Interview was used across 3 time points (baseline, year 1, year 2) to measure the severity of each ARFID profile and evaluate illness persistence or remission, and the Eating Disorder Assessment for DSM-5 was used to evaluate diagnostic crossover.

RESULTS

Across the 2-year follow-up period, half the participants persisted with their original diagnosis, and 3% of participants experienced a diagnostic shift to anorexia nervosa. Greater severity in the sensory sensitivity and lack of interest profiles was associated with higher likelihood of ARFID persistence at year 1 only; greater severity in the fear of aversive consequences profile was associated with higher likelihood of ARFID remission at year 2 only.

CONCLUSION

Findings underscore the distinctiveness of ARFID from other eating disorders and emphasize its persistence over 2 years. Results also highlight the predictive validity and prognostic value of the ARFID profiles (ie, sensory sensitivity, fear of aversive consequences, lack of interest).

A systematic review of COVID-19 and the presentation of avoidant/restrictive food intake disorder and avoidant/restrictive food intake disorder-like symptoms

BACKGROUND

The adverse effects of COVID-19 and the associated restrictions on eating disorder populations have been discussed in recent literature. However, little is known about the presentation of cases with avoidant/restrictive food intake disorder (ARFID) during this period.

AIMS

To explore the extent of the literature on the presentation of ARFID, and ARFID-like cases, during the COVID-19 pandemic.

METHOD

Cochrane Library, CINAHL (EBSCO), PsycINFO (EBSCO), EMBASE (Ovid) and Medline (Ovid) were searched for publications between March 2020 and May 2023. Google Scholar and reference lists were hand searched. At least two reviewers independently screened each paper. Narrative synthesis was used.

RESULTS

Seven papers were included: four case reports and three cohort studies (total ARFID sample of 46). Included papers were assessed as having high (n = 3) or moderate (n = 4) quality. Findings did not suggest an increase in ARFID cases during the COVID-19 pandemic, although it is unclear if this is because of a lack of impact or underrecognition of ARFID. A need for a multidisciplinary approach to differentiate between ARFID and organic causes of ARFID-like presentations (e.g. gastrointestinal effects of COVID-19) was highlighted.

CONCLUSIONS

Publications specifically pertaining to ARFID presentations during the COVID-19 pandemic have been few. Papers found have been of small sample sizes and lack subanalyses for ARFID within broader eating disorder samples. Continued surveillance is needed to evaluate any COVID-19-specific effects on the development, identification, treatment and outcomes of ARFID.

Evaluating a Treatment Package for Avoidant/Restrictive Food Intake Disorder to Increase Food Variety

There is a dearth of published research evaluating behavior-analytic assessment and treatment of avoidant/restrictive food intake disorder (ARFID) given the recent revisions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In this study, therapists conducted periodic food preference assessments to help guide treatment for a typically developing child with ARFID and food selectivity. Further, therapists evaluated a treatment package including demand fading, escape prevention, and self-monitoring to increase food variety. Consumption increased during treatment with target foods; however, preference shifts were minor when compared to the pretreatment food preference assessment. Variety continued to increase overtime using the same treatment package and treatment effects were generalized to family meals and other locations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00821-0.

A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID)

OBJECTIVE

This scoping review identifies and describes psychological interventions for avoidant restrictive food intake disorder (ARFID) and summarizes how outcomes are measured across such interventions.

METHOD

Five databases (Cochrane, Embase, Medline, PsycInfo, Web of Science) were searched up to December 22, 2022. Studies were included if they reported on psychological interventions for ARFID. Studies were excluded if participants did not have an ARFID diagnosis and if psychological interventions were not delivered or detailed.

RESULTS

Fifty studies met inclusion criteria; almost half were single-case study designs (23 studies) and most studies reported on psychological interventions for children and adolescents with ARFID (42 studies). Behavioral interventions (16 studies), cognitive-behavioral therapy (10 studies), and family therapy (5 studies), or combinations of these therapeutic approaches (19 studies) were delivered to support patients with ARFID. Many studies lacked validated measures, with outcomes most commonly assessed via physical health metrics such as weight.

DISCUSSION

This review provides a comprehensive summary of psychological interventions for ARFID since its introduction to the DSM-5. Across a range of psychological interventions and modalities for ARFID, there were common treatment components such as food exposure, psychoeducation, anxiety management, and family involvement. Currently, studies reporting on psychological interventions for ARFID are characterized by small samples and high levels of heterogeneity, including in how outcomes are measured. Based on reviewed studies, we outline suggestions for clinical practice and future research.

PUBLIC SIGNIFICANCE

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by avoidance or restriction of food due to fear, sensory sensitivities, and/or a lack of interest in food. We reviewed the literature on psychological interventions for ARFID and the outcomes used to measure change. Several psychological interventions have been developed and applied to patients with ARFID. Outcome measurement varies widely and requires further development and greater consensus.

Validation of the youth-nine item avoidant/restrictive food intake disorder screen

OBJECTIVE

This study assessed the factorial, divergent, and criterion-related validity of the Youth-Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (Y-NIAS) in a paediatric clinical sample at initial evaluation for an eating disorder (ED).

METHOD

Participants included 310 patients (82.9% female, 77.4% White, Age M = 14.65) from a tertiary ED clinic. Confirmatory factor analysis (CFA) evaluated the three-factor of the Y-NIAS. One-way analysis of variance compared Y-NIAS scores across diagnoses. A receiver operating curve analysis assessed the ability of each subscale to identify ARFID presentations from the full sample. Two logistic regressions assessed the criterion-related validity of the obtained Y-NIAS cut-scores.

RESULTS

CFA supported the original three-factor structure of the Y-NIAS. Clinically-elevated scores were observed in all diagnostic groups except for binge-eating disorder. Subscales were unable to discriminate ARFID cases from other ED diagnoses. Cut scores were identified for picky eating subscale (10) and Fear subscale (9), but not for Appetite subscale. In combination with the ED Examination Questionnaire (EDE-Q), classification accuracy was moderate for ARFID (62.7%) and other EDs (89.4%).

DISCUSSION

The Y-NIAS demonstrated excellent factorial validity and internal consistency. Findings were mixed regarding the utility of the Y-NIAS for identifying clinically-significant ARFID presentations from other ED diagnoses.

Birth-related, medical, and diagnostic characteristics in younger versus older children with avoidant/restrictive food intake disorder (ARFID)

BACKGROUND

Although avoidant/restrictive food intake disorder (ARFID) presents the replacement and extension of feeding disorders of infancy and childhood, previous research into ARFID concentrated mainly on older patients. While birth-related characteristics play an etiologic role in feeding disorders, virtually nothing is known so far in ARFID. Therefore, the first aim of the study was to identify differences in birth-related characteristics in younger vs. older children with ARFID. Second, differences in physical and mental comorbidities, and third, diagnostic features between age groups were analysed.

METHODS

Among N = 51 in- and outpatient treatment-seeking patients, n = 23 patients aged 0-5 years (30% girls) and n = 28 patients aged 6-17 years (57% girls), with an interview-based diagnosis of ARFID were included. Data on the pre- and perinatal period and mental and physical comorbidities were derived from patients' medical records, while diagnostic criteria, main ARFID presentation, and sociodemographic variables were collected through diagnostic interview.

RESULTS

Significantly, younger patients with ARFID were born more often preterm and had more pre- and perinatal complications and a higher incidence of postnatal invasive procedures. Patients with ARFID aged 0-5 years presented significantly more physical comorbidities and conditions, especially congenital anomalies, while mental comorbidities, especially mood disorders, were significantly more common in patients with ARFID aged 6-17 years. No age differences were found for the distribution of diagnostic criteria and main ARFID presentation.

CONCLUSION

This is the first study which aimed to identify age-specific characteristics in patients with ARFID with potential relevance for diagnosis and treatment. Especially birth-related complications, including invasive procedures postnatally, may be associated with developing ARFID, highlighting the importance of a closer view on these potential risk factors of the disorder. Future research with longitudinal design and larger samples may allow more detailed information on further age-specific associations, symptom trajectories, and age-specific risk factors for ARFID.

The clinical presentation of avoidant restrictive food intake disorder in children and adolescents is largely independent of sex, autism spectrum disorder and anxiety traits

Background

Avoidant restrictive food intake disorder (ARFID) is a new eating disorder with a heterogeneous clinical presentation. It is unclear which patient characteristics contribute to its heterogeneity.

Methods

To identify these patient characteristics, we performed symptom-level correlation and driver-level regression analyses in our cross-sectional study in up to 261 ARFID patients (51% female; median age = 12.7 years) who were assessed at the Maudsley Centre for Child and Adolescent Eating Disorders, London between November 2019 and July 2022.

Findings

Symptoms across the three drivers 1) avoidance based on sensory characteristics of food; 2) apparent lack of interest in eating; and 3) concern about aversive consequences positively correlated with each other. Patients' anxiety traits showed the greatest positive correlations with symptoms of concern about aversive consequences of eating. Patient sex was not significantly associated with any of the three ARFID drivers. Patients with comorbid autism spectrum disorder (ASD; 28%) showed more food-related sensory sensitivities (RR = 1.26) and greater lack of interest in eating (RR = 1.18) than those of patients without ASD (49%).

Interpretation

In our clinical sample, the ARFID drivers occurred together and did not show clinically meaningful differences between the sexes. ASD may accentuate food-related sensory sensitivities and lack of interest, but may not drive a completely different symptom presentation. ARFID is multi-faceted and heterogenous, requiring a comprehensive multidisciplinary assessment to sufficiently understand the drivers of the restrictive eating behaviour. Results need replication in larger samples with more statistical power.

Funding

None.

A Systematic Review to Manage Avoidant/Restrictive Food Intake Disorders in Pediatric Gastroenterological Practice

Avoidant/Restrictive food intake disorder (ARFID) is a feeding disorder characterized by persistent difficulty eating, such as limited choices of preferred foods, avoidance or restriction of certain foods or food groups, and negative emotions related to eating or meals. Although ARFID mainly affects children, it can also occur in adolescents and adults. ARFID can have serious physical and mental health consequences, including stunted growth, nutritional deficiencies, anxiety, and other psychiatric comorbidities. Despite its increasing importance, ARFID is relatively underrecognized and undertreated in clinical practice. Treatment consists of a multidisciplinary approach involving pediatric gastroenterologists, nutritionists, neuropsychiatrists, and psychologists. However, there are several gaps in the therapeutic approach for this condition, mainly due to the lack of interventional trials and the methodological variability of existing studies. Few studies have explored the nutritional management of ARFID, and no standardized guidelines exist to date. We performed a systematic literature review to describe the different nutritional interventions for children and adolescents diagnosed with ARFID and to assess their efficacy and tolerability. We identified seven retrospective cohort studies where patients with various eating and feeding disorders, including ARFID, underwent nutritional rehabilitation in hospital settings. In all studies, similar outcomes emerged in terms of efficacy and tolerability. According to our findings, the oral route should be the preferred way to start the refeeding protocol, and the enteral route should be generally considered a last resort for non-compliant patients or in cases of clinical instability. The initial caloric intake may be adapted to the initial nutritional status, but more aggressive refeeding regimens appear to be well tolerated and not associated with an increased risk of clinical refeeding syndrome (RS). In severely malnourished patients, however, phosphorus or magnesium supplementation may be considered to prevent the risk of electrolyte imbalance, or RS.

Examination of pediatric tube feeding schedules and oral intake: A retrospective cross-sectional study

BACKGROUND

A common treatment goal for children dependent on enteral feeding is to advance oral nutrition intake and decrease enteral feeding dependence. The purpose of this study was to investigate the relationship between tube feeding schedule and oral intake in feeding tube-dependent children diagnosed with avoidant restrictive food intake disorder (ARFID).

METHODS

A retrospective chart review was completed including 76 tube-dependent children with ARFID between the ages of 1 and 14 years who were evaluated by a registered dietitian, in conjunction with a multidisciplinary feeding team, during January 1, 2018, to May 31, 2019. Eligible participants were diagnosed with ARFID and receiving enteral nutrition via nasogastric or gastrostomy tube during the time of evaluation. The participants were categorized into groups according to tube feeding schedule type (bolus vs. overnight continuous) and further stratified by severity of oral motor deficit, as documented by the speech language pathologist or occupational therapist: none/mild and moderate/severe. The exclusion criteria included children aged <1 year, appetite stimulant listed as an active medication, overnight enteral feeding infusion of >12 h, or calculated percentage of calories from oral intake not specified. The primary study outcome was dichotomized percentage of oral intake, >0% vs 0%.

RESULTS

Following adjustment for confounders, this retrospective chart review showed statistically higher odds of percentage of oral intake >0% in ARFID patients receiving overnight continuous enteral feeding schedules (odds ratio = 0.20, 95% CI: 0.05-0.83, P = 0.027).

CONCLUSION

A bolus feeding schedule may not promote oral intake in feeding tube-dependent children diagnosed with ARFID.

Bone health in avoidant/restrictive food intake disorder: a narrative review

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is an eating/feeding disturbance characterized by severe food avoidance or restriction that results in faltering growth, nutritional deficiencies, dependence on formula supplementation, and/or significant psychosocial impairment. Compared to other eating disorders, ARFID is observed to have an earlier childhood onset and chronic course without intervention. Childhood represents a sensitive period for longitudinal growth and bone accrual, setting the stage for long-term health outcomes associated with longevity and quality of life, including risk for fracture and osteoporosis.

RESULTS

This narrative review discusses published scientific literature on bone health in individuals with ARFID by describing the current understanding of ARFID's effect on bone health, how common dietary constraints characteristic of ARFID may present unique risks to bone health, and the current clinical recommendations for bone health assessment. Reviewing what is known of clinical data from anorexia nervosa (AN) and similar cohorts, the chronicity and etiology of dietary restriction observed in ARFID are hypothesized to compromise bone health significantly. Although limited, examination of bone health in ARFID patients suggests children with ARFID tend to have shorter stature compared to healthy reference datasets and have lower bone density compared to healthy individuals, similar to those with AN. There remains a substantial knowledge gap in how ARFID may interrupt bone accrual during childhood and adolescence, and subsequent impact on attainment of peak bone mass and peak bone strength. The longitudinal effects of ARFID may be subtle and overlooked clinically in the absence of severe weight loss or growth stunting. Early identification and remediation of threats to bone mass accrual have significant personal and population-level implications.

CONCLUSION

For patients with ARFID, delayed identification and intervention to address feeding disturbances may have a long-lasting impact on various body systems and processes, including those relating to longitudinal growth and bone mass accrual. Further research employing rigorous prospective observational and/or randomized study designs are required to clearly define effects of ARFID, as well as clinical interventions aimed at addressing ARFID-related feeding disturbances, on bone accrual.

A Retrospective Consecutive Controlled Case Series of Underspoon: A Modified-Bolus Placement to Address Behavior That Interfere With Swallowing

Children diagnosed with pediatric feeding disorder (PFD) or avoidant/restrictive food intake disorder (ARFID) may present with comorbid oral-motor delays that often contribute to their failure to consume an adequate volume and/or variety of foods. Once the food enters the mouth, these children may exhibit additional problematic behavior such as expulsion and packing that further averts oral intake. Previous research has evaluated the impact of modified-bolus placement methods, including flipped spoon and NUK® brush, in comparison to upright spoon on expulsion and packing. Whether responses are due to performance or skill deficits, researchers hypothesize that modified-bolus placement may assist with reducing the response effort associated with swallowing. This retrospective consecutive controlled case series assessed the clinical application of an additional modified-bolus placement method, underspoon, to increase food consumption and decrease problematic behavior that interfere with mouth clean for children with PFD or ARFID.

Classification of Children and Adolescents With Avoidant/Restrictive Food Intake Disorder

BACKGROUND AND OBJECTIVES

Evidence suggests that children and adolescents with avoidant/restrictive food intake disorder (ARFID) have heterogeneous clinical presentations. To use latent class analysis (LCA) and determine the frequency of various classes in pediatric patients with ARFID drawn from a 2-year surveillance study.

METHODS

Cases were ascertained using the Canadian Pediatric Surveillance Program methodology from January 1, 2016, to December 31, 2017. An exploratory LCA was undertaken with latent class models ranging from 1 to 5 classes.

RESULTS

Based on fit statistics and class interpretability, a 3-class model had the best fit: Acute Medical (AM), Lack of Appetite (LOA), and Sensory (S). The probability of being classified as AM, LOA, and S was 52%, 40.7%, and 6.9%, respectively. The AM class was distinct for increased likelihood of weight loss (92%), a shorter length of illness (<12 months) (66%), medical hospitalization (56%), and heart rate <60 beats per minute (31%). The LOA class was distinct for failure to gain weight (97%) and faltering growth (68%). The S class was distinct for avoiding certain foods (100%) and refusing to eat because of sensory characteristics of the food (100%). Using posterior probability assignments, a mixed group AM/LOA (n = 30; 14.5%) had characteristics of both AM and LOA classes.

CONCLUSIONS

This LCA suggests that ARFID is a heterogeneous diagnosis with 3 distinct classes corresponding to the 3 subtypes described in the literature: AM, LOA, and S. The AM/LOA group had a mixed clinical presentation. Clinicians need to be aware of these different ARFID presentations because clinical and treatment needs will vary.

Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

The Polish Version of the Avoidant/Restrictive Food Intake Disorder Questionnaire—Parents Report (ARFID-Q-PR) and the Nine Items Avoidant/Restrictive Food Intake Disorder Screen—Parents Report (NIAS-PR): Maternal Perspective

The aim of the present study was to develop and validate the Avoidant/Restrictive Food Intake Disorder Questionnaire—Parents Report (ARFID-Q-PR), a new tool to diagnose ARFID, based on a report submitted by Polish mothers of children aged 2 to 10 years. In total, 167 mothers of boys and girls aged 2 to 10 participated in the study. We used the ARFID-Q-PR and the Nine Items Avoidant/Restrictive Food Intake Disorder Screen—Parents Report (NIAS-PR). In addition, all mothers were asked to provide information on age, sex, height and weight, chronic somatic diseases, neurodevelopmental and mental disorders as well as intellectual disability of their children. Results of the reliability analysis demonstrated that the ARFID-Q-PR had adequate internal consistency (Cronbach’s alpha of 0.84). The stability of the ARFID-Q-PR factorial structure was confirmed. It is composed of three subscales: (1) attitudes to food; (2) justification for restrictions; (3) somatic symptoms. Our findings demonstrated that the ARFID-Q-PR total score was positively associated with the NIAS-PR total score. In addition, children with developmental and mental disorders substantially demonstrated more ARFID symptoms than did the children in the general population. The Polish version ARFID-Q-PR can be used to recognize the ARFID symptoms in young children by the main feeder in the family—mother or father.

Avoidant and Restrictive Food Intake Disorder: Outcomes for 16 Inpatient Cases to Target Oral Consumption Using a Medical and Behavioral Treatment Model

INTRODUCTION

Avoidant and restrictive food intake disorder (ARFID) is characterized by restrictions in oral intake and does not include concerns related to body image. Despite the evidence-based medical and behavioral treatments, there is limited research as they apply to ARFID, but the extant research supports hospital-based behavioral therapy. Individuals with ARFID may have comorbidities that can affect treatment, which requires multidisciplinary treatment to provide effective care. Supplementary sources of nutrition may be required for individuals with this diagnosis to ensure they maintain proper nutritional status (eg, enteral feeding).

METHODS

A record review from 2015 to 2019 identified 16 participants admitted to an inpatient hospital. Of the sample, 75% of participants had a psychiatric diagnosis and 88% of participants experienced an acute event that preceded their feeding difficulties. Each participant received medical oversight, and instead of a standard treatment approach, behavioral treatment components were individualized based on each participants' presentation.

RESULTS

All participants met at least 80% of their admission treatment goals, and 92% of participants who completed their admission consumed 100% of their nutritional needs orally. Follow-up data indicate sustained progress for several months following discharge.

CONCLUSION

Our results suggest that a multidisciplinary, medical, and behavioral treatment model is effective for a variety of clinical presentations of ARFID. More research is needed on triggering events that precede restricted food and liquid intake. In addition, the extent to which these treatment components are preferred should be assessed in an effort to maintain treatment gains after discharge.

Anorexia nervosa: Outpatient treatment and medical management

Anorexia nervosa (AN) is a disabling, costly and potentially deadly illness. Treatment failure and relapse are common after completing treatment, and a substantial proportion of patients develop severe and enduring AN. The time from AN debut to the treatment initiation is normally unreasonably long. Over the past 20 years there has been empirical support for the efficacy of several treatments for AN. Moreover, outpatient treatment with family-based therapy or individual psychotherapy is associated with good outcomes for a substantial proportion of patients. Early intervention improves outcomes and should be a priority for all patients. Outpatient treatment is usually the best format for early intervention, and it has been demonstrated that even patients with severe or extreme AN can be treated as outpatients if they are medically stable. Inpatient care is more disruptive, more costly, and usually has a longer waiting list than does outpatient care. The decision as to whether to proceed with outpatient treatment or to transfer the patient for inpatient therapy may be difficult. The core aim of this opinion review is to provide the knowledge base needed for performing safe outpatient treatment of AN. The scientific essentials for outpatient treatment are described, including how to assess and manage the medical risks of AN and how to decide when transition to inpatient care is indicated. The following aspects are discussed: early intervention, outpatient treatment of AN, including outpatient psychotherapy for severe and extreme AN, how to determine when outpatient treatment is safe, and when transfer to inpatient healthcare is indicated. Emerging treatments, ethical issues and outstanding research questions are also addressed.

Parent strategies for expanding food variety: Reflections of 19,239 adults with symptoms of Avoidant/Restrictive Food Intake Disorder

OBJECTIVE

To characterize helpful parent feeding strategies using reflections on childhood eating experiences of adults with symptoms of Avoidant/Restrictive Food Intake Disorder (ARFID).

METHOD

We explored a unique text-based dataset gathered from a population of N = 19,239 self-identified adult "picky eaters." The sample included adults with symptoms of ARFID as evidenced by marked interference in psychosocial functioning, weight loss/sustained low weight, and/or nutritional deficiency (likely ARFID), and non-ARFID participants. We leveraged state-of-the-art natural language processing (NLP) methods to classify feeding strategies that were perceived as helpful or not helpful. The best classifiers that distinguished helpful approaches were further analyzed using qualitative coding according to a grounded theory approach.

RESULTS

NLP reliably and accurately classified the perceived helpfulness of caregivers' feeding strategies (82%) and provided information about features of helpful parent strategies using recollections of adults with varying degrees of food avoidance. Strategies perceived as forceful were regarded as not helpful. Positive and encouraging strategies were perceived as helpful in improving attitudes toward food and minimizing social discomfort around eating. Although food variety improved, adults still struggled with a degree of avoidance/restriction.

DISCUSSION

Adults perceived that positive parent feeding strategies were helpful even though they continued to experience some degree of food avoidance. Creating a positive emotional context surrounding food and eating with others may help to eliminate psychosocial impairment and increase food approach in those with severe food avoidance. Nevertheless, additional tools to optimize parent strategies and improve individuals' capacity to incorporate avoided foods and cope with challenging eating situations are needed.

Feeding Problems Including Avoidant Restrictive Food Intake Disorder in Young Children With Autism Spectrum Disorder in a Multiethnic Population

We examined feeding problems, including Avoidant Restrictive Food Intake Disorder (ARFID), in preschool children with Autism Spectrum Disorder (ASD). Data were collected from a prospective longitudinal study of 46 children with ASD in a multiethnic, low resource area in Gothenburg, Sweden. Feeding problems were found in 76% of the children with ASD, and in 28%, the criteria for ARFID were met. The study highlights early onset age, the heterogeneity of feeding problems, and the need for multidisciplinary assessments in ASD as well as in feeding problems, and also the need for further elaboration of feeding disorder classifications in children.

Intensive multidisciplinary feeding intervention for patients with avoidant/restrictive food intake disorder associated with severe food selectivity: An electronic health record review

OBJECTIVE

Expert consensus increasingly recognizes intensive multidisciplinary intervention (IMI) as the standard of care to address chronic and severe feeding problems in pediatric populations. In this study, we examined the clinical presentation, intervention characteristics, and treatment outcomes for young children receiving IMI for avoidant restrictive rood intake disorder (ARFID) involving nutritional insufficiencies associated with severe food selectivity.

METHOD

We followed the Strengthening the Reporting of Observational Studies in Epidemiology statement to conduct this retrospective chart review. The review focused on consecutive patients (birth to age 21 years) admitted to the IMI program over a 5-year period (June 2014 to June 2019). Inclusion criteria required micronutrient insufficiencies (vitamins A, B12, C, D, E; folic acid; calcium; iron; and zinc) and chronic mealtime refusal behavior (e.g., turning head away from food/spoon, pushing or throwing spoon, crying, screaming, and leaving the table) associated with severe food selectivity.

RESULTS

Over the 5-year period, 63 of the patients met study entry requirements. Of these, 60 patients (50 boys and 10 girls; mean age = 72 ± 39 months; range = 23-181) completed intervention (95% treatment completion rate). At discharge, dietary diversity improved by 16 new therapeutic foods (range: 8-22), rapid acceptance and swallowing of new foods exceeded clinical benchmarks (80% or > bites), and risk for nutritional inadequacies declined for this patient cohort.

DISCUSSION

Results of the current study support the benefits of IMI to increase dietary variety, improve mealtime behaviors, and enhance nutritional intake for children with ARFID presenting with severe food selectivity.

Validation of the nine item ARFID screen (NIAS) subscales for distinguishing ARFID presentations and screening for ARFID

OBJECTIVE

The Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (NIAS) has three subscales aligned with ARFID presentations but clinically validated cutoff scores have not been identified. We aimed to examine NIAS subscale (picky eating, appetite, fear) validity to: (1) capture clinically-diagnosed ARFID presentations; (2) differentiate ARFID from other eating disorders (other-ED); and (3) capture ARFID symptoms among individuals with ARFID, individuals with other-ED, and nonclinical participants.

METHOD

Participants included outpatients (ages 10-76 years; 75% female) diagnosed with ARFID (n = 49) or other-ED (n = 77), and nonclinical participants (ages 22-68 years; 38% female, n = 40). We evaluated criterion-related concurrent validity by conducting receiver operating curve (ROC) analyses to identify potential subscale cutoffs and by testing if cutoffs could capture ARFID with and without use of the Eating Disorder Examination-Questionnaire (EDE-Q).

RESULTS

Each NIAS subscale had high AUC for capturing those who fit versus do not fit each ARFID presentation, resulting in proposed cutoffs of ≥10 (sensitivity = .97, specificity = .63), ≥9 (sensitivity = .86, specificity = .70), and ≥ 10 (sensitivity = .68, specificity = .89) on the NIAS-picky eating, NIAS-appetite, and NIAS-fear subscales, respectively. ARFID versus other-ED had high AUC on the NIAS-picky eating (≥10 proposed cutoff), but not NIAS-appetite or NIAS-fear subscales. NIAS subscale cutoffs had a high association with ARFID diagnosis, but only correctly classified other-ED in combination with EDE-Q Global <2.3.

DISCUSSION

To screen for ARFID, we recommend using a screening tool for other-ED (e.g., EDE-Q) in combination with a positive score on any NIAS subscale (i.e., ≥10, ≥9, and/or ≥10 on the NIAS-picky eating, NIAS-appetite, and NIAS-fear subscales, respectively).

Feeding and eating problems in children and adolescents with autism: A scoping review

LAY ABSTRACT

Feeding problems, such as picky eating and food avoidance, are common in youth with autism. Other, broader difficulties with feeding and eating (eating disorder symptoms such as restricting food intake or preoccupation with body shape or weight and insistence on specific food presentation) are also common in autistic individuals. Here, we describe the nature and extent of feeding and eating problems in youth with autism. We found no common characteristics (such as severity of autism symptoms) that best describe autistic youth who experience problems with feeding or eating. Almost all studies we reviewed focused on problems with feeding (selective or picky eating), and only a few studies focused on eating disorder symptoms (concern with weight, shape, and/or body image). However, some researchers reported that eating disorder symptoms may occur more often in autistic individuals compared to their peers without autism. Many studies used the terms "feeding" and "eating" problems interchangeably, but understanding the difference between these problems is important for researchers to be consistent, as well as for proper identification and treatment. We suggest future researchers use "eating problems" when behaviors involve preoccupation with food, eating, or body image, and "feeding problems" when this preoccupation is absent. We highlight the importance of understanding whether feeding or eating problems are separate from autism traits, and the role of caregivers and other adults in the child's treatment. Considerations for health-care providers to assist with diagnosis and treatment are also provided.

Health professionals' familiarity and experience with providing clinical care for pediatric avoidant/restrictive food intake disorder

OBJECTIVE

The current study explored the experience and familiarity of pediatric health professionals with avoidant/restrictive food intake disorder (ARFID), and assessed the application of diagnostic criteria in a series of clinical vignettes.

METHOD

Pediatric health professionals were invited to complete an online survey. Data from 93 health professionals from medical and allied health roles who completed the survey were analyzed.

RESULTS

Respondents providing care for pediatric feeding/eating disorders were more likely to report familiarity with ARFID than those not typically providing care for feeding/eating disorders. Clinicians who had provided care for pediatric ARFID reported more confidence in clinical management of ARFID than did those who had not yet provided care for ARFID, though there were overall relatively low levels of confidence in providing care for ARFID. Respondents to the clinical vignettes were more likely to confer a diagnosis of ARFID when there were symptoms of both psychosocial impairment and weight loss than when there was psychosocial impairment alone.

DISCUSSION

The results suggest variability in current application of diagnostic criteria for ARFID, low confidence in clinical management of ARFID, and ambiguity in clinicians' judgments regarding whether psychosocial impairment is sufficient to meet a diagnosis of ARFID.

Treatment Needs and Rates of Mental Health Comorbidity in Adolescent Patients With ARFID

The purpose of this paper is to provide a descriptive overview of a single-center ARFID-specific pilot clinic that sought to better understand the specific needs of patients with ARFID including rates of comorbidities, and to gain insight into treatment requirements. A retrospective cohort study was completed on patients meeting criteria for ARFID admitted to a specialized pilot clinic within a tertiary care hospital. Over an 18 month period, a total of 26 patients were assessed and had follow-up data for a 12 month period. Patients presented with heterogeneous manifestations of ARFID and high rates of comorbid mood and anxiety disorders were noted. Treatment plans were tailored to meet individual needs at assessment and over the treatment period. A multidisciplinary approach was most often administered, including a combination of individual therapy, family therapy, medical monitoring, and prescribed medications. Only 30% of patients were treated exclusively by therapists on the eating disorder team. The experiences gained from this pilot study highlight the need for specialized resources for assessment and treatment of patients with ARFID, the importance of a multidisciplinary approach to treatment, and the necessity of utilization of ARFID-specific measures for program evaluation purposes.

Avoidant/restrictive food intake disorder: Psychopathological similarities and differences in comparison to anorexia nervosa and the general population

INTRODUCTION

Avoidant/restrictive food intake disorder (ARFID) categorises patients with selective and/or restrictive eating patterns in the absence of distorted cognition concerning weight, food, and body image.

OBJECTIVE

To examine the sociodemographic and clinical profile of patients with ARFID in comparison to those with anorexia nervosa (AN) and to a non-clinical group (NCG).

METHOD

A descriptive, observational, comparative study made up of three groups (ARFID, AN and NCG). Ninety-nine children and adolescents were analyzed by means of a semi-structured diagnostic interview and questionnaires on depression, anxiety, clinical fears and general psychopathology.

RESULTS

The ARFID group was significantly younger (10.8 vs. 14.1 years of age), with a greater proportion of males (60.6% vs. 6.1%), an earlier onset of illness (6.2 vs. 13.4 years of age), and a longer period of evolution of the illness (61.2 vs. 8.4 months) compared to the AN group. Clinically, patients with ARFID showed greater medical (42.4% vs. 12.1%) and psychiatric (81.8% vs. 33.3%) comorbidity-assessed with a semi-structured diagnostic interview-greater clinical fear (p < 0.005), more attention problems (p < 0.005) and fewer symptoms of anxiety and depression (p < 0.005)-measured with self-report questionnaires.

CONCLUSIONS

ARFID is a serious disorder with a significant impact on the physical and mental health of the pediatric population. Likewise, some of these physical and mental conditions may be a risk factor in developing ARFID. Attention problems and clinical fears in ARFID, and the greater presence of internalised symptoms in AN, were the main differences found in the psychopathological profiles.

Characteristics of avoidant/restrictive food intake disorder in a general paediatric inpatient sample

OBJECTIVE

Although patients with avoidant/restrictive food intake disorder (ARFID) often consult general paediatric services initially, existing literature mostly concentrated on intensive eating disorder treatment settings. This cross-sectional study sought to describe symptoms of ARFID and their associations with eating disorder psychopathology, quality of life, anthropometry, and physical comorbidities in a general paediatric sample.

METHODS

In N = 111 patients (8-18 years) seeking treatment for physical diseases, prevalence of ARFID-related restrictive eating behaviours was estimated by self-report and compared to population-based data (N = 799). Using self-report and medical record data, further ARFID diagnostic criteria were evaluated. Patients with versus without symptoms of ARFID based on self-report and medical records were compared in diverse clinical variables.

RESULTS

The prevalence of self-reported symptoms of ARFID was not higher in the inpatient than population-based sample. Only picky eating and shape concern were more common in the inpatient than population-based sample. Although 68% of the inpatient sample reported any restrictive eating behaviours, only 7% of patients showed symptoms of ARFID based on medical records in addition to self-report, particularly those with underweight, without significant effects for age, sex, and medical diagnoses.

DISCUSSION

The study revealed the importance of considering ARFID within the treatment of children and adolescents with physical diseases, especially for those with underweight. Further research is needed to replicate the findings with interview-based measures and to investigate the direction of effects in ARFID and its physical correlates.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Editorial to the virtual issue highlighting neuroscience based research in eating disorders to mark the 49th Society for Neuroscience Annual Meeting

OBJECTIVE

This virtual issue of the International Journal of Eating Disorders highlights recently published research that is based on neuroscience concepts, to mark the 49th Society for Neuroscience Annual Meeting in Chicago, IL, in November 2019.

METHODS AND RESULTS

The collection of articles includes research published between 2018 and 2019 that fall within the broader field of clinical neuroscience. Those articles span a broad range of themes, including food intake regulation and reward circuitry, taste perception, decision-making, cognitive and emotional bias, and targeting altered brain circuits using novel therapeutic methods.

DISCUSSION

The eating disorders field as a whole is increasingly incorporating neuroscience-based concepts when studying those disorders and developing disease models. We hope that this virtual issue will further stimulate discussion and research that is focused on brain circuits and neurobiology to study etiology and pathophysiology of eating disorders to develop more effective treatments.

Treatment of avoidant/restrictive food intake disorder for a teenager with typical development within the home setting

INTRODUCTION

Avoidant/restrictive food intake disorder (ARFID) can occur in children with typical development and persist past childhood. This significantly impacts most areas of children's lives, but may become more evident in teenage years, especially socially. There is an empirically supported treatment for ARFID with 40 years of research backing, this being behaviour-analytic feeding interventions. However, application to individuals over age 12 is lacking, and needs to be investigated for effectiveness. This is important as the addition of ARFID (formerly called feeding disorders) to the DSM-V has seen an increase in new treatments for ARFID by attempting to apply eating disorder treatments to this population including children. More research is needed to identify if already established behavioural intervention procedures are effective for ARFID in individuals with selectivity, without disabilities, older ages, and in settings outside of intensive specialised feeding hospital admissions in the United States.

METHOD

A 13-year-old female with ARFID and years of failed treatment attempts participated in her home in Australia. We conducted multiple stimulus without replacement preference assessments and used a changing criterion design with multiple baseline probes. Treatment consisted of demand fading, choice, differential attention, and contingent access. We did not use cognitive or family based treatment.

RESULTS

Consumption increased to 100%. Variety reached 61 foods across all food groups. She met 100% of goals and ate at a restaurant. Caregivers reported high satisfaction and social acceptability. Gains were maintained at 9 months.

CONCLUSION

This brief, behaviour-analytic in-home treatment was effective in increasing food group variety consumption.

Youth with Avoidant/Restrictive Food Intake Disorder: Examining Differences by Age, Weight Status, and Symptom Duration

The primary purpose of this study was to examine differences among youth with avoidant/restrictive food intake disorder (ARFID) by age, weight status, and symptom duration. A secondary goal was to report the frequencies of ARFID using DSM-5 clinical presentations (i.e., fear of aversive consequences, lack of interest in food, sensory sensitivities). Participants (N = 102), ages 8-18 years, were recruited through an eating disorder service within a pediatric hospital. They were evaluated using semi-structured interviews and questionnaires. Patients were assigned to groups according to age, weight status, and symptom duration. Frequencies of clinical presentations, including combinations of DSM-5 categories, were also examined. Our findings suggest that adolescents presented with higher rates of Depression (p = 0.04). Youth with chronic ARFID symptoms presented with significantly lower weight (p = 0.03), and those with acute symptoms rated significantly higher suicidal ideation and/or self- harm (p = 0.02). Half of patients met criteria for more than one ARFID symptom presentation. This study provides preliminary evidence that youth with ARFID differ in clinical presentation depending on age, weight status, and symptom duration, and highlights safety concerns for those with acute symptoms of ARFID. High rates of overlapping symptom presentations might suggest a dimensional approach in the conceptualization of ARFID.

Introduction to a special issue on child and adolescent feeding and eating disorders and avoidant/restrictive food intake disorder

OBJECTIVE

We are very pleased to introduce a special issue of the International Journal of Eating Disorders on child and adolescent feeding and eating disorders and avoidant/restrictive food intake disorder (ARFID).

METHOD

Contributions focused on five main themes: (1) the definition and assessment of ARFID; (2) the clinical phenomenology of ARFID; (3) similarities and differences between ARFID and anorexia nervosa (AN); (4) novel treatments for ARFID; and (5) new ideas for improving treatment outcomes in AN.

RESULTS

These papers highlight the importance of clear operationalization and measurement of the ARFID diagnostic criteria. ARFID phenotypes bear both similarities and important differences in clinical profile, course, and outcome from AN. Findings suggest the utility of adapting existing treatments for restrictive eating disorders to apply to ARFID and engender clinical creativity to move beyond existing treatments and develop novel interventions that address the heterogeneity of ARFID. Furthermore, burgeoning understanding of ARFID offers the potential that novel treatments for ARFID may also be applied to improve outcomes for AN.

DISCUSSION

This collection of papers features child and adolescent feeding and eating disorder patient groups that have been understudied and we hope that this catalyzes clinical research in these important presentations.