Restrictive Food Intake disorder

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PARENT GUIDE

Avoidant/Restrictive Food Intake Disorder

By

Troumbly Melanie

Moore Bernice

Hester Roseline

Gray Susan

Dumas Remiluc

Overview

The negative belief that food intake goes beyond weight control as sensory characteristics of food can lead to a commanding or strict diet. Avoidant Restrictive Food Intake Disorder (ARFID) is a new eating disorder diagnosis, involves limitations in the amount or types of food consumed, however unlike anorexia, ARFID does not involve body dysmorphia (Norris, et. al, 2014). Mal development from inadequate intake gives way to the differential diagnosis of an eating disorder, which clarity into predominant diagnosis sow from diagnostic tools and comparison to DSM 5 criteria. Confirming the diagnosis of a selective eating disorder can be challenging given margin differences are slim.

Signs and Symptoms

Signs and symptoms of avoidant/restrictive food intake disorder includes the avoidance or restriction of food intake manifested by the clinically significant failure to meet requirements for nutrition or insufficient energy intake through oral intake or food (American Psychiatric Association, 2013).

· Significant weight loss, defined as a failure to achieve expected weight gain or faltering growth in children (American Psychiatric Association, 2013; Brigham et al., 2018).

· Significant nutritional deficiency (American Psychiatric Association, 2013; Brigham et al., 2018; Thomas et al., 2017).

· Dependence on enteral feeding or oral nutritional supplements, including tube feedings or high-energy supplements (American Psychiatric Association, 2013; Brigham et al., 2018; Thomas et al., 2017).

· Marked interference with psychosocial functioning (American Psychiatric Association, 2013; Brigham et al., 2018).

· Restricted eating or feeding due to lack of interest in eating or low appetite (Brigham et al., 2018; Thomas et al., 2017).

· Inability to eat certain foods based on aversions to specific tastes, textures, or smells, often meats, vegetables, and/or fruits (Brigham et al., 2018; Thomas et al., 2017).

· Excluding entire food groups (Brigham et al., 2018).

· Avoiding situations with food (Brigham et al., 2018).

· Difficulty digesting certain foods (Brigham et al., 2018).

· Significant weight loss or failure to achieve expected weight gain (Thomas et al., 2017).

· Being afraid to eat after a choking or vomiting episode (Brigham et al., 2018; Thomas et al., 2017).

Pathophysiology

According to Brigham et al., to be diagnosed with Avoidant/Restrictive Food Intake Disorder(ARFID), an individual must have problematic eating habits, which may be due to an inability to tolerate specific sensory properties of food (e.g., texture, taste, appearance); a fear of potential adverse consequences of eating (e.g., choking, vomiting); or an overall lack of interest in food or eating. These alterations must be significant enough to cause either weight loss or failure to gain appropriate weight in growing children, nutritional deficiencies, dependence on nutritional supplements, or psychosocial dysfunction (2018). Diagnostic markers include:

· Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).

· Significant nutritional deficiency.

· Dependence on enteral feeding or oral nutritional supplements.

· Marked interference with psychosocial functioning.

· The disturbance is not better explained by a lack of available food or associated culturally sanctioned practice (American Psychiatric Association, 2013).

Food avoidance or restriction may also represent a conditioned negative response associated with food intake following, or in anticipation of, an aversive experience, such as choking; a traumatic investigation, usually involving the gastrointestinal tract (e.g., esophagoscopy); or repeated vomiting (Bryant-Waugh et al. 2010).

Risk and Prognostic Factors

Temperamental
– Anxiety disorders, autism spectrum disorder, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder may increase the risk for avoidant or restrictive feeding or eating behavior characteristic of the disorder.

Environmental
-Higher rates of feeding disturbances may occur in children of mothers with eating disorders.

Genetic and physiological
-History of gastrointestinal conditions, gastroesophageal reflux disease, vomiting, and a range of other medical problem

Gender
– is equally common in males and females in infancy and early childhood, but ARFID comorbid with autism spectrum disorder has a male predominance

Diagnosis

The negative belief that food intake goes beyond weight control as sensory characteristics of food can lead to a commanding or strict diet. Avoidant Restrictive Food Intake Disorder (ARFID) is a new eating disorder diagnosis, involves limitations in the amount or types of food consumed, however unlike anorexia, ARFID does not involve body dysmorphia (Norris, et. al, 2014). Mal development from inadequate intake gives way to the differential diagnosis of an eating disorder, which clarity into predominant diagnosis sow from diagnostic tools and comparison to DSM 5 criteria. Confirming the diagnosis of a selective eating disorder can be challenging given margin differences are slim.

Differential Diagnosis 

Problematic eating disorders are misconceptions derive from either biological, psychological, and sociocultural. Common differential diagnoses amongst eating disorders include anorexia nervosa, bulimia nervosa, and selective eating (ARFID) are more likely to have a comorbid anxiety disorder and less likely to have comorbid depression (Brigham, et. al, 2018). The crucial differences between AN, BN, ARFID is body image, the interest in food, and intense anxiety. The presence of two or more general disorders requires diagnosis to selective eating disorder but perceives the threat of reaction of eating selective foods allocates to Avoidant Restrictive Food Intake Disorder.

Diagnostic Tools

Understanding and treating Avoidant Restrictive Food Intake Disorder first requires making a confirmed diagnosis, which psychometric measures yield near conclusive.  The Children’s Eating Attitudes Test (ChEAT) assess eating disorder symptoms in which patients that meet the criteria for ARFID had significantly lower total scores on these measures relative to patients meeting criteria for AN and BN, indicating fewer classic eating disorder symptoms (Cooney, et. al, 2018). Formidable psychometric measures for ARFID include Children’s Depression Inventory as this aid in ruling out depression and identifies if higher comorbidity of anxiety, which correlates. Though there is no “gold standard “measure for ARFID, evidence base practice has shown favor to using medical evaluation, ChEAT, and CDI for presumptive diagnosis.

DSM V

Redefining of the diagnosis feeding disorder led way Avoidant Restrictive Food Intake Disorder expand its criteria’s along with associated ages.  According to the DSM, ARFID is defined as a persistent failure to meet nutritional or energy needs and leading to one or more of the following: significant weight loss, nutritional deficiency, dependent on secondary enteral, or interference with psychological function (Fisher, et. al, 2013). The underlying motives are very different than the distorted body image as it pertains to taste, text, smell, or presentation of the food along with past traumatic experiences. The common name “Picky Eater” indicates inaccurate information and incorrect beliefs about food intolerance and nutrition.

Treatment Options

Avoidant/restrictive food intake disorder (ARFID) is perceived as a form of eating disorder, where people eat food selectively, based on taste, smell, presentation, texture, or a past experience with certain kind of food. Individuals with ARFID tend to experience significant weight loss and nutritional dependency, leading to reliance on nutritional supplements and poor psychosocial functioning. With time, individuals with ARFID can experience a decline in symptoms without any form of treatment, but in most cases, treatment is required to prevent symptoms from persisting into adulthood. Working with a psychiatrist mental health nurse practitioner (PMHNP) to transform one’s behaviours is beneficial in combatting this condition.

One of the widespread treatment approaches for ARFID is the cognitive behavioural therapy (CBT), which assists children engage in regular eating and self-monitoring of their food intake. In particular, CBT for ARFID is designed for children greater than 10 years of age and adults, where the PMHNP engage patients in 20 to 30 sessions, which are split into four stages, to assist them resolve nutritional deficiencies (Thomas et al., 2018). This form of therapy postulates that some individuals possess biological predispositions to sensory sensitivity, as well as lack interest in food, leading to nutritional deficiency. CBT is also applied to enable patients deal with anxiety as they approach recovery.

Family-based therapy (FBT), which is a gold-standard treatment for children and adolescents with anorexia nervosa, is a suitable treatment option for ARFID, particularly for children who are underweight. According to Spettigue et al. (2018), family-based therapy usually focuses on removing the blame on children’s behavior, and creating awareness on the risks of having low weight and malnutrition. Family therapy sessions provide education to family members on how to offer compassion to the patients, assist parents to empathize with the pain and fear that their children are experiencing in addition to encouraging them to develop diaries to evaluate their weight gain. FBT is accompanied by parent training, where parents are empowered through enhancing child’s nutrition, with an aim of gaining a healthy weight. Consequently, children with ARFID are exposed to novel foods, as well as increased dietary volume.

SPACE-ARFID is a parent-based treatment approach for outpatients with ARFID, where parents are largely involved in handling child problematic eating habits. Shimshoni and Yaara (2020) termed SPACE-ARFID (Supportive Parenting for Anxious Childhood Emotions Adapted for Avoidant/Restrictive Food Intake Disorder) as a psychotherapeutic approach that focuses on promoting flexibility, as well as adjustment in issues related to food, where parents are involved in transforming children’s behaviors, thus, helping them alleviate distress linked to the disorder. SPACE-ARFID also increases supportive responses towards children’s symptoms. Registered dietitians are responsible for dietary and nutritional treatments, but they are expected to collaborate with parents for successful reduction of chronic eating disorders.  

Other forms of treatment for ARFID include hospital-based re-feeding programs, which incorporate tube feeding, as well as adjunctive pharmacotherapy. Adjunctive pharmacotherapy involves treating patients within the hospital using medications such as mirtazapine and olanzapine, to increase appetite and to enhance the rate of weight gain (Norris et al., 2020). Hospital-based re-feeding programs enable children who have lost weight through avoiding food to have structured and uninterrupted mealtimes, which enables them gain weight within a stipulated time frame (Rossler, 2014). However, more research is required to investigate the effectiveness of numerous therapies and medications, or a combination of treatment options for ARFID in adults, as well as children.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author

Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018). Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Current pediatrics reports, 6(2), 107–113.

https://doi.org/10.1007/s40124-018-0162-y

Cooney, M., Lieberman, M., & Guimond, T. (2018) Clinical and psychological features of children and adolescents diagnosed with avoidant/restrictive food intake disorder in a pediatric tertiary care eating disorder program: a descriptive study. J Eat Disord 6, 7 (2018). https://doi.org/10.1186/s40337-018-0193-3

Fisher, M., Rosen, D., Ornstein, R., Mammel, K., Katzman, D., and Rome, E. (2013) Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5 Journal of Adolscent Health Vol.55 Issues 1, July 2014, Pages 49-52

https://doi.org/10.1016/j.jadohealth.2013.11.013

Lock, J., & La Via, M. C. (2015). Practice parameter for the assessment and treatment of children and adolescents with eating disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 54(5), 412–425. Retrieved from

http://www.jaacap.com/article/S0890-8567(15)00070-2/pdf

Norris, M., Obeid, N., Santos, A., Valois, D., Isserlin, L., Feder, S., & Spettigue, W. (2020). A single-center experience with service organization for patients with ARFID. Research Square.

https://doi.org/10.21203/rs.3.rs-22008/v1

Norris ML, Robinson A, and Obeid N. (2014) Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord. 2014;47:495-499.

Rossler, L. (2014). Eating disorders and artificial re-feeding. Mental Health Practice, 9, 21. doi: 10.7748/mhp.17.9.21. e854

Shimshoni, Y., & Lebowitz, E. R. (2020). Childhood ARFID: Review of Treatments and a Novel Parent-Based Approach. Journal of Cognitive Psychotherapy. https://doi.org/10.1891/JCPSY-D-20-00009

Spettigue, W., Norris, M. L., Santos, A., & Obeid, N. (2018). Treatment of children and adolescents with avoidant/restrictive food intake disorder: a case series examining the feasibility of family therapy and adjunctive treatments. Journal of Eating Disorders, 6(1), 20. https://doi.org/10.1186/s40337-018-0205-3

Thomas, J. J., Lawson, E. A., Micali, N., Misra, M., Deckersbach, T., & Eddy, K. T. (2017). Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Current psychiatry reports, 19(8), 54.

https://doi.org/10.1007/s11920-017-0795-5

Thomas, J. J., Wons, O., & Eddy, K. (2018). Cognitive-behavioral treatment of avoidant/restrictive food intake disorder. Current opinion in psychiatry, 31(6), 425. https://doi.org/10.1097/YCO.0000000000000454