An Overview of Psychological Interventions for Avoidant Restrictive Food Intake Disorder (ARFID)

Dr. Emma Willmott is experienced in working with children and young people presenting with ARFID, and supporting their families, having worked across community-based and national and specialist NHS CAMHS services, including the Feeding and Eating Disorder Service at Great Ormond Street Hospital (GOSH) and the ARFID Service at Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED) at SLAM, where she currently works as a Senior Clinical Psychologist.

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Marking its tenth anniversary as a diagnosis, our scoping review summarised 50 studies reporting on psychological interventions and outcomes for Avoidant Restrictive Food Intake Disorder (ARFID). In the absence of clinical guidelines to support clinicians, our review highlights that a range of psychological interventions can be implemented to support children and young people with ARFID. Here, we summarise the existing literature and highlight areas for further research. 

A young, curly haired African American girl sits bored looking at food. Do not want to eat food.

What is ARFID?

ARFID was first introduced to our mental health diagnostic manuals ten years ago (American Psychiatric Association, APA, 2013). ARFID was introduced as a new diagnostic entity, in part, to replace and extend the DSM-IV diagnosis of “feeding disorder of infancy or early childhood”, a diagnosis restricted to children six years or younger (Zimmerman & Fisher, 2017). Compared to this, ARFID can emerge and/or persist across the life stages (Sharp & Stubbs, 2019).

ARFID is characterised by avoidant and restrictive eating behaviours resulting from a lack of interest in eating, avoidance due to the sensory properties of food, and/or fear-based concerns, such as worries about choking or vomiting following eating (APA, 2013). By contrast, anorexia nervosa (AN) is characterised by persistent dietary restriction relating to body image concerns and/or fear of weight gain (APA, 2013). The presence of weight concerns or body image distortions is encompassed in the exclusion criteria of ARFID (APA, 2013; Barney et al., 2022). Compared to those with AN, individuals with ARFID have been identified as younger, report an earlier age of onset, and have a higher percentage median Body Mass Index (% BMI) (Becker et al., 2019).

To receive a diagnosis of ARFID, one of four criteria must be met: (1) significant weight loss/failure to gain weight as expected, (2) significant nutritional deficiency, (3) dependence on nutritional supplements or enteral feeding, and/or (4) interference in psychosocial functioning. Additionally, the avoidant/restrictive eating should not be attributed to concurrent or mental health conditions nor be better explained by lack of available food or cultural practices (APA, 2013).  ARFID is largely accepted to be a heterogenous condition, with its presentation and consequences varying from person to person.

The number of children and young people living with ARFID varies widely depending on population and setting examined. A systematic review found the estimated prevalence of ARFID in non-clinical child and adolescent samples ranged between 0.3% to 15.5%, with higher estimates of up to 55.5% 64% in eating disorders services and feeding disorders services, respectively (Sanchez-Cerezo et al., 2023).

At present, there are no evidence-based treatment recommendations to guide care for patients with the condition (National Institute of Health and Care Excellence, NICE, 2017). In the absence of clinical guidance, our review highlights a range of psychological interventions that clinicians can draw upon in practice to support children and young people presenting with ARFID.

Psychological Interventions for ARFID

Our review identified 50 studies, 42 of which focused on child and adolescent populations and a further two studies that included mixed child and adult participants. The main intervention modalities adopted included behavioural approaches, cognitive behavioural therapy (CBT), family interventions, or combinations of these. Regardless of the main therapeutic modality, we noticed that there often appeared to be common elements to ARFID interventions including direct food exposure, psychoeducation on ARFID, nutrition, and/or anxiety, general anxiety management, involvement of family members/carers, and treatment generalisation. This may suggest that these components have an important and helpful role in psychological interventions for ARFID. Additionally adjunctive treatments were often included, such as psychiatric medications, nutritional support or supportive therapies such as speech and language therapy.

Behavioural interventions

Behavioural interventions were the most common form of psychological intervention for children and young people with ARFID, applied to those aged 2 to 15. Such approaches often drew upon reinforcement strategies, including contingent reinforcement, such as providing a reward for a bite of food, and differential reinforcement, such as providing praise and attention for a desired behaviour and ignoring undesirable eating behaviours. Behavioural interventions were mostly parent-focussed, skilling up parents using therapeutic modelling and in vivo feedback. Interventions also often included ‘mealtime hygiene’ strategies (e.g., time limits for meals). Whilst most of the studies drew upon general behavioural principles, some were more formalised and structured and were delivered by Applied Behavioural Analysis (ABA) therapists.

Cognitive behavioural interventions

These interventions used a combination of cognitive and behavioural techniques (e.g., cognitive restructuring, behavioural experiments, exposure to feared foods) and often also focused on broader anxiety management strategies. The intervention often focused on alleviating the specific fear affecting eating (e.g., fear of choking), through targeting maintaining cognitions and safety-seeking behaviours. Some studies followed a cognitive behavioural manual developed for ARFID specifically (CBT-AR) (Thomas & Eddy, 2019) or were delivered by therapists specifically trained in CBT. CBT interventions were applied to those aged 10 and over.

Family interventions

Family interventions were focused on those aged 21 and under. Most family studies followed family-based treatment (FBT), adapted for ARFID (Lock et al., 2019) and delivered across a range of ARFID presentations. Several studies involved multi family therapy, either as the main therapeutic component or as part of a multi-modal intervention, for example, as part of partial hospitalisation programmes.

Outcomes and the Evidence-Base

A striking finding was that across the 50 studies, there was little consistency on how to measure change during interventions for ARFID, making it hard to compare treatments. The most common way to measure outcomes was through physical health measures, especially changes in weight. Perhaps this is because weight is an easy metric, however, it could be argued this is not always the most relevant means to assess change given that individuals with ARFID can present across the weight spectrum, and weight loss may not be pertinent to an individual’s experience or presentation of ARFID.

The second most common way to measure outcomes was through nutritional and dietetic changes, measured in a variety of ways, for example, by caloric intake, new foods added, or the overall number of foods accepted in the diet. Some studies used validated psychological measures and few employed measures specific to ARFID. Outcomes were often measured in individualised and idiosyncratic ways, reflecting patient goals and priorities for care. For example, in one study the goal was to no longer require an oral nutritional supplement whereas, in another, the goal was to support a patient to accept a supplement.

From a research perspective, there is a need for consensus on how to measure change, so that we can compare treatments more easily, and eventually identify which treatments are most effective. However, the wide variety of ways used to measure change may also point to another issue: that the ARFID diagnosis itself is broad and heterogenous. As a result, achieving consensus on how change should be measured in ARFID may be difficult.

Overall, the evidence-base for ARFID currently consists mostly of heterogenous single-case reports, which limits the conclusions that can be drawn regarding the effectiveness of psychological interventions for ARFID. Larger scale studies and randomized controlled trials with adequate statistical power are necessary to establish the efficacy of interventions.

Implications

From the studies included in the review, we recommend that the most appropriate choice of psychological intervention should be guided by formulation. Clinicians should consider a range of factors including the patients’ age/developmental stage, the specific presentation and driving factors of ARFID, any physical/nutritional risks, comorbid conditions, and patient preferences and goals. Additionally, a multidisciplinary approach to care is often required.  Clinicians also need to consider how to measure outcomes, including what measures would reflect meaningful change for ARFID patients.

In terms of research, there is a need for studies that bring together people with lived experience of ARFID, their families/carers, as well as clinicians and researchers, to work out how best to measure change in treatment studies. Studies are needed across diverse samples, including different ethnicities and regions of the world. Ultimately, larger scale studies should be conducted so we can develop evidence-based guidelines on what works for whom.

Conclusions

Our review highlights that a range of psychological interventions can be applied to children and young people with ARFID. Whilst a range of psychological approaches can be drawn upon (e.g., behavioural, CBT, family interventions), these typically have some common elements, such as food exposure, psychoeducation, anxiety management, and family/carer involvement.

Our review also highlights that a range of treatment options for ARFID have been developed in the past ten years, although further research is needed before we can say which treatments work best. Nevertheless, our findings should prove helpful to people with ARFID, their parents/carers, and clinicians, by providing an up-to-date review of psychological treatments.

Conflicts of interest

Emma Willmott and Tom Jewell were first and last authors of the review article discussed in this blog. They report no other conflicts of interest.

Links/References

Full scoping review

Reference for the scoping review:

Willmott, E., Dickinson, R., Hall, C., Sadikovic, K., Wadhera, E., Micali, N., Trompeter, N. & Jewell T. (2023) A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID). Int J Eat Disord: https://doi.org/10.1002/eat.24073

References cited in the blog:

American Psychiatric Association. (2023). The American Psychiatric Association practice guideline for the treatment of patients with eating disorders (5th ed.) Washington, DC: American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890424865

Barney, A., Bruett, L. D., Forsberg, S., Nagata, J. M. (2022). Avoidant Restrictive Food Intake Disorder (ARFID) and Body Image: a case report. Journal of Eating Disorders, 10(1), 1-3, https://doi.org/10.1186/s40337-022-00583-0

Becker, K. R., Keshishian, A. C., Liebman, R. E., Coniglio, K. A., Wang, S. B., Franko, D. L., Eddy, K. T. & Thomas, J. J. (2019). Impact of expanded diagnostic criteria for avoidant/restrictive food intake disorder on clinical comparisons with anorexia nervosa. International Journal of Eating Disorders, 52(3): 230-238, https://doi.org/10.1002/eat.22988

Lock, J. E., Robinson, A., Sadeh-Sharvit, S., Rosania, K., Osipov, L., Kirz, N., Derenne, J., & Utzinger, L. M. (2019). Applying family-based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa. International Journal of Eating Disorders52(4), 439–446. https://doi.org/10.1002/eat.22994

National Institute for Health and Care Excellence. (2017). Eating disorders: recognition and treatment. NG69. Available from https://www.nice.org.uk/guidance/ng69/resources/eating-disorders-recognition-and-treatment-pdf-1837582159813

Sanchez-Cerezo, J., Nagularaj, L., Gledhill, J., & Nicholls, D. (2023). What do we know about the epidemiology of avoidant/restrictive food intake disorder in children and adolescents? A systematic review of the literature. European Eating Disorders Review31(2), 226–246. https://doi.org/10.1002/erv.2964

Sharp, W. G., & Stubbs, K. H. (2019). Avoidant/restrictive food intake disorder: A diagnosis at the intersection of feeding and eating disorders necessitating subtype differentiation. International Journal of Eating Disorders52(4), 398–401.

Thomas, J. J., & Eddy, K. T. (2019). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder children, adolescents, and adults. Cambridge University Press.

Zimmerman, J. & Fisher, M. (2017). Avoidant/Restrictive Food Intake Disorder (ARFID). Current problems in paediatric and adolescent health care, 47(4), 95-103.

Authors

Dr Emma Willmott

Dr. Emma Willmott is experienced in working with children and young people presenting with ARFID, and supporting their families, having worked across community-based and national and specialist NHS CAMHS services, including the Feeding and Eating Disorder Service at Great Ormond Street Hospital (GOSH) and the ARFID Service at Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED) at SLAM, where she currently works as a Senior Clinical Psychologist.

Tom Jewell

Dr. Tom Jewell is a Lecturer in Mental Health Nursing at King’s College London, with a clinical and research interest in adolescent eating disorders. He is a mental health nurse and family therapist and works clinically at Great Ormond Street Hospital.

Discussion

This is a good read as my daughter age 10 has been diagnosed with ARFID. She was under CAMHs and the feeding clinic and when she made a bit of improvement she was discharged from services. Currently her weight has dropped and her anxiety has spiked so we have been referred back to the feeding clinic. I do feel more professionals in Suffolk needs to be aware of ARFID and how to support children with a diagnosis. Also there needs to be more mental health support available to children in this area.

Awesome Read!
Thanks Emma and Tom

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