Avoidant/Restrictive Food Intake Disorder (ARFID)

With the publication of the DSM-5 has come a revised conceptualization of an old eating disorder. Avoidant/Restrictive Food Intake Disorder (ARFID) has replaced Feeding Disorder of Infancy and Early Childhood, which was described in the DSM-IV. The latter category was very rarely used, and there is almost no information on the characteristics of the children who have it.

The new category of ARFID is intended to capture individuals who meet criteria for the existing DSM-IV category, but also to include other individuals with clinically significant eating problems who are not included in the defined DSM-IV categories, and therefore must be assigned a diagnosis of Eating Disorder Not Otherwise Specified (EDNOS). The first critical element in the DSM-5 definition of ARFID is a persistent disturbance in eating that leads to significant clinical consequences, such as weight loss or inadequate growth, a significant nutritional deficiency, dependence on tube feeding or nutritional supplements to sustain adequate intake, and/or impaired psychosocial functioning, such as an inability to eat with others.

Significant weight loss and potential nutritional deficiencies should be assessed in a similar way as they are assessed in anorexia nervosa (AN), because physical complications seen in AN ( such as hypothermia, bradycardia, or anemia) may also occur in individuals with potential ARFID. Three additional criteria in DSM-5 are intended to exclude individuals who have a clinically significant problem that is better described in some other way. For example, a diagnosis of ARFID would not be given if the nutritional problems are better explained by a lack of available food or a cultural practice (such as religious fasting), or if the person has substantial and irrational dissatisfaction with body shape or weight (such as in AN or bulimia nervosa (BN), or if the clinical problem is better accounted for by an existing medical condition or another mental disorder.

Clinically Significant Restrictive Eating Problems Are Key

ARFID was developed to identify individuals presenting with clinically significant restrictive eating problems, including some that meet criteria for the DSM-IV diagnosis of Feeding Disorder of Infancy and Early Childhood. Common eating disturbances seen in a clinical setting that have previously been classified under Feeding Disorder of Infancy and Early Childhood include: impaired development of feeding or eating skills, difficulty with digesting or with intake of fluids or foods, refusal to eat due to a dislike of certain sensory characteristics of foods, and a more general lack of appetite or interest in eating (Bryant-Waugh et al. 2010). All of these presentations will still be classified under ARFID, as will other eating disturbances that previously would have been classified under EDNOS, including:

• Inadequate intake based on a restricted range of foods eaten or a restricted caloric intake that does not lead to weight loss or significant growth impairment. Individuals with this problem may avoid foods based on certain sensory qualities- such as texture, color, taste, or temperature. An example could be a child who likes only foods that he does not have to chew, and who therefore has great difficulty consuming a range of foods adequate to sustain normal growth and development.
• Reduced food intake due to an emotional disturbance related to eating, without concern for body shape or weight. These may arise if there are significant problems in the relationship between the child and the caregiver so that meals became fraught with anxiety and unpleasant interactions, so that food intake is repeatedly and seriously interrupted.
• Reluctance regarding food intake following an eating-related adverse event. A person who significantly restricts food intake due to a reluctance to swallow following a frightening episode of gagging, choking or vomiting may be diagnosed with ARFID.

Reasons for the Change in the DSM-5

In the DSM-IV, Feeding Disorder of Infancy or Early Childhood was a diagnosis rarely given and rarely studied. In fact, a recent PubMed search using this diagnostic term identifies no publications within the past 10 years. To meet criteria for the DSM-IV condition, an individual must be under 6 years of age at the time of illness onset, and must persistently fail to eat adequately to gain or maintain a healthy weight for at least 1 month, if no other digestive problem or mental disorder can better account for the observed eating disturbance (Diagnostic and Statistical Manual of Mental Disorders (2000) 4th ed., text rev). In the DSM-IV, a difficult parent-child relationship is emphasized as a potential factor in the development of this feeding disorder. For example, parents who present food or respond to a refusal to eat inappropriately may contribute to an infant developing a general uneasiness around eating. Additionally, the DSM-IV suggests that infants with feeding disorders are more likely to have unpredictable, intrusive, and over-stimulating mothers, who are also more likely to have mental illnesses such as depression or an eating disorder compared to infants without feeding disorders (Chartoor et al., 1998; Lindberg et al., 1996). For this reason, some believe feeding disorders in infancy should be “relational,” and the focus should be on the influence of such parental and environmental factors (Bryant-Waugh et al. 2010), as outlined in the definition from the DSM-IV. Since little is known about the clinical utility of Feeding Disorder of Infancy or Early Childhood and it is not a common diagnosis, the criteria were re-evaluated for the DSM-5.

Limitations of the Former Criteria

The diagnostic criteria of a Feeding Disorder in Infancy or Early Childhood have apparent limitations, which are addressed and modified in the DSM-5’s definition of ARFID. One limitation of the older diagnosis was its emphasis on weight loss or a failure to gain weight as a necessary clinical determinant of this illness. It is possible that a child may have a disturbance in eating and is avoiding food, yet still manages to gain or maintain a healthy weight (possibly due to a reliance on nutritional supplements), thus excluding him or her from getting a feeding disorder diagnosis (Bryant-Waugh et al. 2010).

Individuals with an eating disturbance that interferes with psychosocial functioning may have a clinically significant condition and would, of course, benefit from identification and appropriate treatment, yet the focus on weight loss in the DSM-IV definition may have interfered with such a patient receiving clinical attention. Another limitation to the DSM-IV definition of feeding disorders in infancy is the criterion that onset must occur before age 6, most commonly during the first few years of life, potentially as a result of negative interactions with the caregiver. However, this is clearly not always the case. Clinicians see older adolescents and even adults with a disturbance in eating that impacts either nutrition or social functioning in a negative way (Kreipe & Palomaki 2012), and it is important to evaluate, diagnose, and possibly treat these individuals.

Finally, the definition of feeding disorders in infancy includes in its criteria that the disturbance cannot be “due to” some other general medical condition. However, distinguishing a medical condition from a feeding disorder can be difficult, as it is common for an individual with a feeding disorder to have a coexisting medical issue. The revised diagnosis in DSM-5 has been expanded to include clinically significant food avoidance or restriction, with or without an associated medical condition. If the feeding disturbance itself leads to clinically significant changes in nutrition, weight, or social functioning in an individual, a diagnosis of ARFID should be given.

Development, Course, and Clinical Expression of ARFID

While few data on ARFID have been published, it appears that it usually presents in infancy or childhood, but it can also present or persist into adulthood. For example, aversion to food after a negative event such as choking can occur at any age, while avoidance based on sensory characteristics of food usually starts in early childhood. When presenting in infancy, associated features may include irritability, sleepiness, and distress, and parents may have a difficult time engaging their child in feeding (Zero to Three, 2005). In older children or adolescents, the eating disturbance may be related to emotional difficulties. In the past, similar presentations of eating disturbances related to emotional difficulties (such as low mood or generalized anxiety) were termed “food avoidance emotional disorder,” or FAED (Higgs, Goodyer & Birch, 1989; Bryant-Waugh, 2010).

The course of illness for individuals who develop ARFID is, at the moment, relatively unknown. Avoidance due to sensory characteristics of food may be enduring and last into adulthood (Mascola, Bryson & Agras, 2010). While it is conceivable that individuals with ARFID may go on to develop another eating disorder such as Anorexia Nervosa, no prospective studies are yet available. In children and adults, ARFID may be associated with impaired social functioning and affect family functioning, especially if there is great stress surrounding mealtimes.

Distinguishing ARFID from Other Disorders

The presence of other psychological disorders may be risk factors for ARFID, such as anxiety disorders, obsessive-compulsive disorders, attention deficit disorders, and autism spectrum disorders (Timimi, Douglas & Tsiftsopolou, 1997). If an individual presents with one of these illnesses and an eating problem, a diagnosis of ARFID should be given only when the feeding disturbance itself is causing significant clinical impairment that requires intervention beyond that usually required for the other condition. Similarly, individuals with a history of gastrointestinal conditions such as gastroesophageal reflux may develop feeding disturbances, but a diagnosis of ARFID should be assigned only when the feeding disturbances require significant treatment beyond that needed for the gastrointestinal problems.

Treating ARFID

Little is currently known about effective treatment interventions for individuals presenting with ARFID. However, given the prominent avoidance behaviors, it seems likely that behavioral interventions, such as forms of exposure therapy, will play an important role. For someone with an emotional disturbance such as depression or anxiety that affects feeding (such as in FAED), cognitive behavioral therapy and other treatments for the underlying condition may be an effective approach for treatment of the eating disorder.

Conclusions

Idiosyncratic patterns of food intake commonly develop during childhood, but have no clinical significance and remit without intervention. For example, children commonly refuse to eat Brussels sprouts, and this does not constitute an eating disorder! However, the creation of a more inclusive diagnostic category for ARFID should be beneficial in permitting a more specific diagnostic label to be given to clinically significant symptoms that could otherwise go un-identified or untreated. Additionally, since a systematic literature does not yet exist, the definition of ARFID in DSM-5 will hopefully facilitate research to determine the incidence, prevalence, and outcomes of this eating disturbance.