Avoidant/restrictive food intake disorder

Avoidant/restrictive food intake disorder is not simply "picky eating" commonly seen in toddlers and young children, which usually resolves on its own. In other cases, ARFID subjects may eat a variety of foods but, due to lack of interest or low appetite, not eat enough to meet growth and/or nutritional needs. People with ARFID may also be afraid of trying new foods, a fear known as food neophobia. For some people with ARFID, multiple reasons for undereating apply. Autism A 2023 review concluded that "there is considerable overlap between ARFID and autism," finding that 8–55% of children diagnosed with ARFID were autistic. The most common symptom seen in patients with both autism and ARFID is sensory-based avoidance; however, fear-based restriction and lack of interest in food are prevalent in this population as well. Anxiety disorder Anxiety disorders are the most common comorbidity with ARFID. 36–72% of people struggling with ARFID also have a diagnosed anxiety disorder. Specific food avoidances could be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Most eating disorders are related to a fear of gaining weight. Those who have ARFID do not have this fear, but the psychological symptoms and anxiety created are similar. Some people with ARFID have fears such as emetophobia (fear of vomiting) or a fear of choking. Anorexia nervosa Anorexia nervosa is distinguished from ARFID by the fact that body image or weight concerns motivate food restriction. However, the distinction between the two disorders is not always clear and there can be overlap. A person with anorexia nervosa, for example, may initially restrict food intake due to body concerns, but, over time, get over those concerns yet still undereat due to nausea and anxiety around food, fitting ARFID's low-appetite presentation. Alternately, an adolescent may at first restrict intake due to severe sensory processing issues, often seen in ARFID, and later develop body image concerns. Family-based therapy (FBT), initially developed to treat anorexia nervosa, is also used to treat children and teens with ARFID. Attention deficit hyperactivity disorder Those with attention deficit hyperactivity disorder (ADHD) often struggle with inattentiveness or distraction, which may lead to missing meals or forgetting to eat for long periods of time. Additionally, people with ADHD are more likely than the general population to struggle with mood disorders, such as anxiety and depression, which have a strong link with ARFID. Obsessive–compulsive disorder ARFID is known to co-occur with obsessive–compulsive disorder (OCD). Common overlap in symptoms include obsessions related to food and food intake or rituals related to eating. Major depressive disorder People with ARFID are more likely to have major depressive disorder than the general population. However, more clinical research is needed to better understand the relations between ARFID and major depressive disorder, as well as other mood disorders. == Diagnosis ==

Diagnosis is often based on a diagnostic checklist to test whether an individual is exhibiting certain behaviors and characteristics. Clinicians will look at the variety of foods an individual consumes, as well as the portion size of accepted foods. They will also question how long the avoidance or refusal of particular foods has lasted, and if there are any associated medical concerns, such as malnutrition. Criteria The DSM-5 published in 2013 was the first to include ARFID as a diagnosis. A diagnosis of ARFID can also be given if the full criteria are no longer met for a sustained period of time. In this case, it is specified that the person is in remission. Assessment The Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) has been developed to assess the presence of ARFID. Across nine items that are scored on a 6-point Likert scale, the NIAS assesses picky eating, appetite, and fear scale. == Treatment ==

As of June 2024, diagnostic tools and treatment protocols for ARFID are still in the process of development. According to a review from the Journal of Eating Disorders, the limited understanding of avoidant and restrictive eating and its neurobiology poses challenges to effective treatment and management. Pharmacological interventions: The U.S. Food and Drug Administration has not approved any psychotropic medication for treatment of ARFID, and empirical evidence on this front is currently extremely limited. However, small case studies have pointed to a few possible pharmacological interventions: olanzapine, a second-generation atypical antipsychotic; mirtazapine, an antidepressant known for its safety and efficacy in treating depressive and anxious symptoms in adults; and buspirone, typically used to treat generalized anxiety disorder. Responsive feeding treatment involves a support person establishing mealtime routines with pleasant interactions and modeling to encourage the person struggling with ARFID to respond to hunger cues. Cognitive behavioral therapy A suitable treatment for older children and adults alike is CBT-AR (Cognitive Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder), in which one study found 90% of participants had high levels of satisfaction with the program. While the rate of remission to this type of program is said to be around 40%, This workbook includes psychoeducation about ARFID, self-monitoring records for food logs, and the different stages in treatment. The treatment is broken up into four stages and aimed to help "reduce nutritional compromise and increase opportunities for exposure to novel foods to reduce negative feelings and predictions about eating". In a simplified format, the stages of this treatment are: • Psychoeducation regarding ARFID and CBT-AR, setting up a regular pattern of eating and self-monitoring. • Psychoeducation about nutrition deficiencies, selecting new foods to help aid the loss of those deficiencies. • Figuring out the root cause(s) of the patient's ARFID, bringing in 5 new foods to examine, describe their features and try tasting them throughout the week, lastly exposure to the foods in the sessions. • Evaluating progress and compiling a relapse prevention plan. This is set to take place over 20–30 sessions ranging from six months to a year. == Prevention ==

While there is currently no way to predict who will develop ARFID, there may be ways to help reduce the probability of developing a disorder or reducing its severity. A child over age 3 or 4 who falls downward across 2 percentile curves on the weight chart is a cause for concern. Families can help mitigate future eating problems by establishing appropriate feeding practices at home. This includes avoiding bribing or coercing children into eating different foods, which may cause backlash and heighten anxiety around eating. The parent is responsible for when, where, and what the food is, and the child is responsible for how much they eat. == Epidemiology ==

Unlike most eating disorders, there may be a higher rate of ARFID in young boys than there is in young girls. Presentations are often heterogenous. Additionally, literature suggests that parental pressure for a child to eat could potentially have a negative impact on the child's food intake. This is associated with picky eating and a decrease in weight during childhood. This can be contributing to the child's hunger cues, as well as the child eating for reasons other than their hunger (e.g., emotions). In a study conducted between 2008 and 2012, 22.5% of children aged 7–17 in day programs for eating disorder treatment were diagnosed with ARFID. Other risk factors include sensory processing sensitivity, gastrointestinal disease, and anxiety associated with eating. Prevalence among children aged 4–7 is estimated to be 1.3%, and 3.7% in females aged 8–18. Prevalence of ARFID compared to picky eating Children are often picky eaters, but this does not necessarily mean they meet the criteria for an ARFID diagnosis. ARFID is a rare condition, and though it shares many symptoms with regular picky eating, it is not diagnosed nearly as much. Selective eating, or picky eating, which can exhibit symptoms similar to those of ARFID, can be observed in 13–22% of children from ages 3–11, whereas the prevalence of ARFID has "ranged from 5% to 14% among pediatric inpatient eating disorder (ED) programs and as high as 22.5% in a pediatric ED day treatment program." == History ==

Prior to the DSM-5, the DSM was not inclusive in recognizing all of the challenges associated with feeding and eating disorders in 3 main domains: It can be detrimental, as a broad scope can lead to false positive diagnoses of ARFID, though as an advantage it is better than the DSM-IV description which landed people with ARFID in the "EDNOS" (eating disorder not otherwise specified) category and made it more difficult for people with the condition to reach potential treatment. == References ==