Avoidant/Restrictive Food Intake Disorder (ARFID)

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Avoidant/restrictive food intake disorder (ARFID) is an entirely new diagnosis in the DSM-5. ARFID replaces “feeding disorder of infancy or early childhood,” which was a diagnosis in the DSM-IV restricted to children 6 years of age or younger; ARFID has no such age limitations and it is distinct from anorexia nervosa and bulimia nervosa in that there is no body image disturbance. ARFID involves a complex and heterogenous etiology, which is reviewed herein. What is known to date regarding the characteristics and medical and psychiatric comorbidities of this patient population are described and compared to other eating disorders. Evaluation and management strategies are also discussed. No data yet exist regarding ARFID׳s prognosis and prevention; however, recommendations to guide parents in establishing appropriate infant and child feeding practices are provided.

Introduction

May 2013 marked the much-anticipated publication of the Diagnostic and Statistical Manual, 5th Edition1 (DSM-5) by the American Psychiatric Association (APA). The first major update since 1994, the DSM-5 includes extensive revisions throughout, and includes the new section, “feeding and eating disorders,” which replaces and combines two former sections, “eating disorders” and “feeding and eating disorders of infancy or early childhood.” The new “feeding and eating disorders” section includes expanded criteria for familiar diagnoses, such as anorexia nervosa (AN) and bulimia nervosa (BN), as well as several new diagnoses, including purging disorder and avoidant/restrictive food intake disorder (ARFID), the latter of which replaces “feeding disorder of infancy or early childhood,” which was a diagnosis in the DSM-IV restricted to children 6 years or younger. ARFID is not genuinely a new condition, but this restrictive eating disorder was not clearly defined and characterized until the publication of the DSM-5 in 2013. ARFID is an entirely new diagnosis within the section of feeding and eating disorders in the DSM-5. The DSM-5 provides diagnostic specificity to those patients who do not fear weight gain, but simply cannot meet their nutritional needs for a variety of reasons. The diagnosis of ARFID in the DSM-5 does not have an age restriction; it can therefore be applied to children, adolescents, and adults. However, since the age groups in which it is most commonly diagnosed are older children and younger adolescents, it is most often pediatricians who are called upon to be the first practitioners to consider the diagnosis.

As early as 1992, Lask and Bryant-Waugh2 describe several childhood-onset eating disorders involving food restriction that failed to meet criteria for AN due to lack of body image distortion or a desire to lose weight. In 2002, Watkins and Lask3 expanded on these atypical eating disorders in children and adolescents and classified them as follows: food avoidance emotional disorder, characterizing children with a “primary emotional disorder in which food avoidance is a prominent feature;” selective eating, describing children who “eat very few different foods and sometimes are particular about the brand of food or where the food was bought” but whose growth and development is not negatively impacted by their eating patterns; functional dysphagia, which involves a “fear of swallowing, vomiting, or choking, which makes the child anxious about and resistant to eating normally, which results in a marked avoidance of food,” and for which there is typically “an easily identifiable precipitant, such as having witnessed someone choking while eating;” and pervasive refusal syndrome, affecting a smaller number of children, but which is “a potentially life-threatening condition manifested by a profound and pervasive refusal to eat, drink, walk, talk, or care for themselves in any way over a period of several months.” None of these disorders involve body image distortion or a desire to lose weight, and as their descriptions indicate, there is a constellation of reasons why these patients, who would now be diagnosed with ARFID, do not meet their nutritional needs.

Indeed, ARFID may be the eating disorder with the most heterogenous etiology. Several subcategories have emerged in the research published thus far that attempt to define the reasons behind restricted nutritional intake. In a retrospective study conducted among seven adolescent medicine divisions, 712 patients presented for initial evaluations of eating disorders during a 1-year period, and 98 (13.8%) met criteria for ARFID. According to documented symptoms, 28.7% of ARFID patients had selective eating since early childhood, 21.4% experienced generalized anxiety, 19.4% had gastrointestinal symptoms, 13.2% had a history of vomiting or choking, 4.1% had food allergies and 13.2% had other reasons for their restricted eating.4 Another study divided 33 ARFID patients into the following four groups: insufficient intake/little interest in feeding (57.6%), limited diet due to sensory characteristics of food (21.2%), aversive/traumatic experience (9.1%), and other reasons (12.1%).5

ARFID is distinct from anorexia nervosa and bulimia nervosa in that there is no body image disturbance; ARFID patients may express a desire to increase their eating and gain needed weight, but they simply cannot get themselves to do it. The reasons behind this inability appear to be as varied as the patients themselves. The literature to date has identified some common patterns, which may be used to inform the course of treatment. ARFID is similar to other eating disorders in that management involves a multidisciplinary team approach and includes medical, nutritional, and psychological practitioners. However, the role each discipline plays may vary to a greater degree than for other types of eating disorders based on the many variants in the etiology of the ARFID diagnosis. As ARFID has been in existence as an official diagnosis for less than four years, available literature is primarily limited to retrospective chart reviews and single case studies.

Section snippets

Diagnosis

As noted earlier, while feeding and eating disorders of infancy and early childhood in the DSM-IV was limited to children not older than 6 years, ARFID has no diagnostic age restrictions. ARFID distinguishes a cohort of individuals who experience persistent difficulty in meeting their nutritional needs despite a lack of body image or weight concerns. The DSM-5 sets forth four diagnostic criteria, titled criterion A through D, each of which must be satisfied for a diagnosis of ARFID to be made.

Epidemiology and Etiology

With the introduction of ARFID and other new and revised diagnoses in the DSM-5, the number of “unclassified” eating disorders declined dramatically. Patients now diagnosed with ARFID would previously have been relegated to eating disorder not otherwise specified (EDNOS), a catch-all diagnosis in the DSM-IV for patients not meeting full criteria for other eating disorders such as anorexia nervosa or bulimia nervosa. A study in our own division of adolescent medicine demonstrated the improvement

Medical and Psychiatric Comorbidities and Complications

While ARFID encompasses a broad spectrum of etiologies, it has been consistently demonstrated that ARFID patients are more likely to be younger, male and have a higher incidence of comorbid medical or psychiatric disorders compared to those with other eating disorders.4, 5, 11, 12 Higher rates of OCD4, 11 and generalized anxiety disorder4, 5, 11, 12 have been reported by multiple sources. Higher rates of autism spectrum disorder, learning disorders, and cognitive impairment have been reported

Evaluation and Management

No empirical data have been published regarding evaluation and treatment since the inception of ARFID in the DSM-5; treatment has primarily been described in case studies or studies in which ARFID was retrospectively diagnosed with chart reviews. Management considerations include the effect on weight and growth, the extent of nutritional compromise, the impediment of social and emotional function,6 as well as whether the patient is considered a long-term or short-term ARFID sufferer. The nature

Prevention and Prognosis

Limited information is available regarding all aspects of ARFID, and there are simply not yet adequate data to determine the expected course of illness and prognosis of a patient with ARFID. While there is no way to predict who will develop ARFID, pediatricians should be aware of the high parental concern regarding child food intake. In particular, many parents are concerned that their child does not eat enough, often leading to the parent pressuring or bribing the child to eat even when the

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