Avoidant Restrictive Food Intake Disorder Alana MacDonald Specialist CAMHS Dietitian and CBT Therapist

What is ARFID? DSM-5 Descriptor (The Diagnostic and Statistical Manual of Mental Disorders, American Psychiatry Association, 2013): An eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 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. DSM V diagnosis from its release in 2013. children, adolescents and adults Will be ICD 11 – Previously known as EDNOS. May also be more generally thought of as ‘extreme’ food fussiness

What is ARFID 2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. 3. The eating disturbance does not occur exclusively during the course of AN or BN, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. 4. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. Same physiology as patients with AN but lack a distorted body image etc – they do not eat sufficient nutrition due to other factors than fear of weight and shape.

Presents as 3 Sub-Types Low Interest or ‘Limited Intake’= Individuals who do not eat enough/show little interest in eating; Sensory or ‘Limited Variety’= Individuals who only accept a limited diet in relation to sensory features; Fear or ‘Aversive’= History occurred and/or evolved due to specific anxiety or fear related to food and/or eating (e.g chocking event, nausea, traumatic event ). (Bryant-Waugh et al. Int J Eat Dis 2010; Norris et al, 2018)

Low Interest / Limited Intake Sub Type Overall low appetite Long standing May appear to lack interest in food, seem not to experience hunger, or become easily full Usually no restriction in terms of variety or texture Act of eating can be difficult (drawn out meal times, small bites etc) Often suboptimal energy/nutritional intake which impacts weight/growth/development

Sensory/Limited Variety sub type ‘Picky’ eating. Sensory food avoidance. Long standing. Unwillingness to try new foods based on sensory characteristics (taste, smell, texture etc). Rigidity around process of eating (food prep, cutlery etc). May occur in context of ASD. Differing age at presentation. Functional and/or developmental impairment becomes more apparent at older age (adolescent). Selective eating Again, not a formal diagnosis but a descriptive term referring to a group of children who many clinicians working with age group will be familiar with : Characterised by Long standing, highly selective pattern of food intake in terms of range accompanied by an unwillingness to try new foods (this has also been called food neophobia). Common in young children – also seen later in childhood and adolescence, particularly in boys (GOS ratio approx 4:1). At GOS about 10% of referrals. In older children often becomes more restricted in relation to anxiety / stress. Tends to become clinically significant through social avoidance, anxiety and family conflict, though does not always do so. Physically tend to be OK, and within normal weight and height ranges. They do often report unpleasant symptoms such as gagging, vomiting, retching, abdominal pains though usually only when trying new foods.

Fear / Aversion Sub Type Food avoidance due to emotional disorder/ functional dysphagia/ post traumatic feeding disorder Specific fear around one or more foods or food types or around consequence of eating e.g. vomiting/diarrhoea Avoidance of food related to the above Consequences of avoidance vary in severity Abnormal cognitions about weight and shape not usually present May result in dependency on enteral feeding (naso-gastric or PEG)

Assessment Assessment for people with ARFID must be multi-disciplinary, utilising skills from professions such as Speech and language therapists, Occupational Therapists, Psychologists, Family therapists and Paediatricians. Any physical / physiological reason for Food avoidance / eating difficulties should be rules out. Dietitians have a key role, and in addition to core dietetic assessment, in CAMHS we would be paying attention to feeding/eating practices/routines, sensory issues and feeding and medical history.

Treating the specific sub-types Lack of interest Reassurance re growth. Monitoring. Meal time structure. Establishment of routine. Parenting strategies/reduce conflict. FBT / family based Approach? Sensory food avoidance Expectations (e.g. in ASD) Sensory work, sensory diet Patient led strategies for neophobia Hierarchies Guided imagery Goal based Phobic type Address medical and nutritional concerns Treat as anxiety disorder – usually CBT informed approach with parent involvement depending on age

References Norris et al. Building evidence for the use of descriptive sub types in youth with Avoidant restrictive food intake disorder. International Journal of Eating Disorder 2018; 51: 170 - 173 Sharp WG et al. A systematic review and meta-analysis of intensive multidisciplinary intervention for paediatric feeding disorders: How standard is the standard of care?. The journal of paediatrics 2017; 181: 116 – 124. Child and Adolescent Eating Disturbances. Dasha Nicholls, Consultant child psychiatrist at Great Ormond Street Hospital. Presented at SEDIG Conference, Nov 2017. Treatment of Avoidant/Restrictive Food Intake Disorder: Not one size fits all! By Rachael Bryant-Waugh, consultant Clinical Psychologist at Great Ormond Street Hospital. Presented At the International Eating Disorders Conference in March 2017. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Bryant-Waugh, R., Markham, L., Kreipe, R. E., & Walsh, B. T. (2010). Feeding and eating disorders in childhood. International Journal ofEating Disorders, 43, 98–111. https://doi.org/10.1002eat.20795Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational& Psychological Measurement, 20, 37–46.