Family-Based Treatment for Avoidant/Restrictive Food Intake Disorder

James D. Lock

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000442472
• Edition: 1
• Topic: Psychologie
• Subtopic: Abnormale Psychologie

This book describes the theoretical and clinical rationale for the use of Family-Based Treatment (FBT) for Avoidant/Restrictive Food Intake Disorder (ARFID).

Based on years of clinical care and systematic study of children and adolescents with ARFID using Family-Based Treatment for Avoidant/Restrictive Food Intake Disorder (FBT-ARFID), the manual provides guidance about assessment of ARFID. Topics covered include how to incorporate the medical, nutritional, and psychiatric problems that are common with this disorder and how to evaluate the principle maintaining behaviors related to lack of interest or appetite, extreme sensory sensitivities to food, and fear of physical repercussions of eating (e.g. pain, vomiting, allergic reactions). Step-by-step illustrations of the key interventions in FBT-ARFID are provided and detailed case discussions demonstrate how these are implemented in a range of cases.

Ideal for clinical practitioners who treat children and adolescents with eating disorders, specifically, psychologists, psychiatrists, social workers, and allied health practitioners.

1 What is Avoidant/Restrictive Food Intake Disorder?

DOI: 10.4324/9781003042020-2

In this chapter we describe Avoidant/Restrictive Food Intake Disorder (ARFID), the specific diagnostic characteristics, differences between ARFID and other eating disorders, prevalence, etiological theories, risks, common presentations, and common co-morbidities—both medical and psychiatric. The purpose of the chapter is to help therapists using this manual to have a ready reference for understanding ARFID and to consolidate the existing literature for efficient use by practicing clinicians.

Historical Context

The diagnostic category Avoidant/Restrictive Food Intake Disorder (ARFID) was first introduced to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in its fifth iteration (DSM-5) in 2013 (American Psychiatric Association 2013). Of course, the clinical problems that are described as constituting this “new” disorder had been present in patients previously, but were variously diagnosed using other diagnostic formulations including Feeding Disorders of Infancy and Early Childhood, Eating Disorder Not Otherwise Specified (EDNOS), Specific Phobias, and various psychosomatic diagnostic categories. None of these diagnostic categories, however, were satisfactory diagnostic homes for the range of eating problems that ultimately has come to be called ARFID. Many with these eating problems were found in infants or young children, and the vagueness of EDNOS failed to capture the specificity of the eating problems and therefore provided little guidance about treatment. In addition, while some patients with ARFID had fears about choking or regurgitation, the conceptualization of the eating problem as a specific phobia was a misnomer. The interplay between psychiatric symptoms and physical health that characterized psychosomatic disorders was a somewhat better fit, but the putative unconscious and psychodynamic underpinnings of this diagnostic category did not align with the usual gradual onset and maintenance of the eating problems for many with ARFID. In sum, then, patients often were diagnosed without much specificity, treated with a range of interventions that were applied without much standardization, treated by a range of professionals often with little mental health training, and in clinics that were not specific to eating problems or disorders (Eddy et al. 2015). Needless to add, perhaps, is that this jumble made it largely impossible to study this condition and develop systematic interventions, understand better the risks for the disorder, and identify ways to prevent it. While the elaboration of the diagnosis of ARFID in DSM-5 has done much to improve this situation, there remain significant challenges about the coherence of this diagnostic formulation (Bryant-Waugh and Kreipe 2012).

Current Diagnostic Criteria

According to the DSM-5, to meet diagnostic criteria for ARFID there are four cardinal features:

1. A clinically significant and sustained difficulty with eating for health;
2. No clinically significant body image disturbance or fear of weight gain;
3. Not diagnosed with anorexia or bulimia nervosa; and
4. The feeding and eating problem is not the result of another medical problem.

If these eating behaviors are sustained the health of the child in terms of weight, growth, and nutritional deficiencies can become severely compromised. In some cases, these types of nutritional impacts can be forestalled through the use of nutritional supplements, tube or enteral feeding short term, but when dependency on such measures develop, the diagnosis of ARFID is more likely. Finally, the result of these eating problems must lead to significant psychosocial impairment. While this criterion is subject to clinical interpretation, the intent is to exclude children and adolescents with mild food phobias, dislikes, and struggles over eating with parents and instead require that these problems rise to the level that interfere with actual social, school, and family functioning and are associated with distress and dysfunction.

A cardinal feature of ARFID is the requirement that there be no body image disturbance associated with the eating problem. This is a crucial distinction between ARFID and other eating disorders such as AN and BN. Body image disturbance is defined as an over valuation of weight and shape as a source of self-worth or self-esteem. A person with normative valuation of appearance related to weight and shape could have ARFID. An adolescent who worries about being too fat or too thin within the context of developmental norms that might often be greater than an adult or child could also have ARFID. What constitutes “disturbance” in body image is not precisely defined, but operationally and practically, if the eating behaviors are used to influence or change body weight or shape, there is a high likelihood that there is body image disturbance and ARFID is not the correct diagnosis.

Excluding the presence of a diagnosis of AN or BN is an extension of the criterion excluding body image disturbance. Body image disturbance is a key feature of both of these “classical” eating disorders. Importantly, however, this criterion expands upon body image disturbance because other criteria used to diagnose AN or BN (and others) also appear to overlap with the criteria to diagnose ARFID. For example, fear of weight gain, a criterion for AN, might be confused with fear of choking or vomiting which are found in some types of ARFID. Similarly, low weight, another key feature of AN, is often found in patients with ARFID, but importantly, low weight in ARFID does not result from attempts to lose weight, but rather a consequence of inadequate nutrition without this purpose. The behaviors of under eating in ARFID may look like dieting, but are not intentional dieting to lose weight. There may be similar medical problems in ARFID patients with low weight as with AN—such as bradycardia (low heart rate), variable or low blood pressure, and low body temperatures—but again, these are the result of malnutrition common to both conditions. Because some ARFID patients may over eat—especially foods they particularly favor—this behavior might sometimes be confused with binge eating in BN or Binge Eating Disorder (BED). However, unlike BN, ARFID patients are not compensating for caloric restriction nor do they feel guilty afterward or try to purge their foods to prevent weight gain. Some ARFID patients may vomit as a response to eating, but again, this is not compensatory nor aimed at preventing weight gain. Instead, vomiting, when it occurs in ARFID, is typically a response to anxiety about choking or another physical reaction (allergic or other medical reaction) rather than to affect weight.

The last criterion for ARFID is the exclusion of a medical condition as the primary cause of the eating disturbance. This does not mean that there can be no medical condition contributing to the eating problem, but rather that the eating problem requires treatment above and beyond the resolution of the medical problem. Indeed, many patients with ARFID are first identified in the context of treatments for medical conditions, especially gastrointestinal (GI) disorders. For example, in a retrospective examination of the source of clinical referrals for ARFID about half of the patients came from a medical clinic (Eddy et al. 2015). This can be a source of confusion for patients, parents, and physicians because the symptoms of ARFID appear related to the GI disorder (and may indeed be in part), so hopes are often pinned on the notion that the eating problem will resolve with the successful treatment of the GI problem. Indeed, many mild to moderate eating disturbances in this context do resolve themselves and do not require separate treatment. However, for those that do not resolve themselves, a diagnosis of ARFID and treatment for the condition is warranted.

Clinical Presentations of ARFID

While there are no systematically or scientifically verified “subtypes” of ARFID, there are three major clinical presentations that are typical: Lack of interest in eating or low appetite; sensory sensitivity or highly selective eating; and fear of adverse consequences of eating such as choking, vomiting, or allergic reactions. While each of these presentations differs in terms of clinical symptoms, all currently fall under the diagnostic category of ARFID. In future, these presentations may be codified as true differing subtypes, or alternatively may be diagnostically separated. As a relatively recent diagnostic category this kind of ambiguity is to be expected, and still is a major advance over the previous scattered diagnostic categories used for these behaviors before the ARFID diagnosis was introduced. Let’s delve a bit deeper into these different presentations to illustrate the range and heterogeneity of ARFID.

Lack of Interest (LOI)

Lack of interest (LOI) or low appetite is a common form of ARFID that often is associated with a long duration, beginning in a number of cases with failure to thrive as an infant. These patients are underweight, though not always markedly so, and usually track in the lower percentiles for height and overall growth. While they may be otherwise progressing well in their development, concerns about low appetite and under eating have usually been long standing for the parents and medical providers. The parents have often tried to promote increased eating, but have not been successful and have “given up” the fight. Children with LOI usually present between the ages of 4–10 and are usually indifferent to any consequence of under eating and do not experience a problem with their eating except for fighting with their parents about it. These children usually eat the full range of foods but only in small quantities. Some may show a preference for fruits and vegetables over proteins and complex carbohydrates, which can also contribute to low weight or poor weight gain. Usually these children do not like to spend time eating or sitting at the table and prefer to talk, play, or otherwise engage themselves. They sometimes forget to eat because of these other interests and when at school they often prefer recess activities to lunch. The parents often find themselves “begging” their child to eat but the child remains blithely unresponsive to this.

Alyssa is a bright, energetic 6-year-old whose parents bring her into the clinic for evaluation because the pediatrician is concerned that she is very short and underweight for her age. Her parents report that Alyssa has always been small and thin. Even as an infant she did not suckle readily and she required supplemental bottle feeds. Nonetheless, she developed normally from a motor, behavioral, and cognitive perspective meeting expected milestones, except her weight has always below the tenth percentile. Her parents are of average height and weight and Alyssa’s sister, 1.5 years younger, is already heavier and taller than Alyssa. Her parents describe how their efforts to get Alyssa to eat more were unsuccessful. She would sit at the dinner table playing with her food or talking rather than eating. They tried punishing her, but they felt bad about this because she said she couldn’t eat because her stomach hurt or she was full.

Sensory Sensitivity (SS)

Sensory sensitivity (SS) or highly selective eaters are another common presentation of ARFID. These children should not be confused with children who are simply somewhat choosey or whose palettes are still developing and do not like stronger tasting foods. Instead, these children display extraordinary sensitivity to taste, texture, and sometimes temperature and color of foods. The classic example of such a child is a young boy who will eat only plain pasta, white bread, and cheerios. These bland foods are predictably tolerated because they do not lead to high sensory sensations of any kind. They are easy to chew, look plain, have little taste and little smell. Often these foods also need to be served at close to room temperature if they are to be consumed. In contrast, these children reject any foods that they perceive as increasing sensations—sauce, green vegetables, many meats (because of the texture and smell), and even mildly spiced foods. As with LOI, these predilections are using long standing, often beginning in toddlerhood. Also similar to LOI, parents have often tried to change these eating patterns to no avail because rejection of any unacceptable foods raises anxiety about insufficient nutrition. These children may be underweight, normal weight, or even overweight depending on how much they eat and what their choices are. Many will consume sugary drinks and foods (like boxed cereals) with low nutritional value but with high calories. Sometimes these children have other psychiatric problems, especially related to attention, oppositional behavior, and autism spectrum disorders.

Tony is a 9-year-old boy whose parents bring him to the evaluation because they are worried about his nutrition. They say he has always been picky about what he eats, beginning at age 1 or 2. They have tried repeatedly to get Tony to eat, but he refuses. He currently eats a very limited diet that includes white bread, plain pasta, fruit juices without pulp, processed cereal, string cheese, and soft drinks. Tony appears slightly overweight, pale, and has a sullen demeanor. He says his parents constantly “bug” him about eating and he is tired of it. He can’t help what tastes good or bad to him, he says, and when they try to make him eat, he gets angry. Tony has seen a therapist in the past for oppositional behavior and attention problems.

Fear of Adverse Consequences (FAC)

The third typical presentation of ARFID is fear of adverse consequences from eating (FAC). Patients with ARFID who present this way usually report a relatively acute onset of symptoms, lasting weeks of months rather than years, as is often the case with LOI and SS presentations. These children and adolescents are usually older than children with LOI or SS though this is not always the case. In most cases of FAC ARFID there is an identifiable precipitating event that triggered the eating disturbance. Common events include sudden unexpected choking or gagging, vomiting, or allergic reaction to a food that starts off the fear. Children with FAC change their patterns of eating in response to these events by decreasing their intake, changing the foods they will eat, and increasing efforts to avoid anxiety about eating. Decreasing intake is accomplished by simply not eating meals or snacks for fear that if they do the choking, gagging, or vomiting will recur. Many children and adolescents with FAC ARFID will only eat liquid, pureed, or very soft foods for the same reasons. They expect these foods will be easier to swallow and therefore think they are safe to consume. Fear is the main emotion children with this form of ARFID experience and in this way, they are similar to the fear of eating that children with AN experience. This fear can be extreme and associated with behavioral dysregulation, again not unlike adolescents with AN who are asked to eat. However, this fear is not related to weight gain or appearance, but instead to a ...