Eating disorders experts weigh in on Avoidant/Restrictive Food Intake Disorder -- two years after classification as a mental health condition
Jessie is a five-year-old girl who doesn't like foods with much texture or flavour. She prefers to eat foods that don't require lots of chewing, like soup, pasta, or oatmeal. Jessie has difficulty eating a range of foods and her mother struggles daily with getting her to consume the nutrients she needs to grow and thrive. Jessie is the smallest child in her class and has been severely underweight for two years.
Jason is a 10-year-old boy who was not a picky eater at all, until he nearly choked on a hot dog eight months ago. The hot dog dislodged and he did not require medical attention immediately after the incident; however, since that day Jason has been reluctant to eat out of fear of choking. He refuses most foods most of the time, but occasionally accepts milk, yogurt and soft cheeses. He has not gained weight since the incident, and with puberty looming ahead, his parents are growing more concerned by the day.
For years, doctors did not have the necessary tools to diagnose children like Jessie and Jason. Did they have "traditional" eating disorders like anorexia nervosa? No, because they did not have distorted body image or a desire to lose weight.
In May 2013, a new category of eating disorder emerged in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), a psychiatric classification and diagnostic tool used across North America. Now, two years later, a new commentary by experts from The Hospital for Sick Children (SickKids) and the Children's Hospital of Eastern Ontario (CHEO) reflects on the clinical impact of the diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID), and the work that remains in terms of treatments and improved outcomes. The commentary is published in the June 18 online edition of the Journal of Adolescent Health.
The classification of ARFID expanded upon a previous diagnostic category of Feeding Disorder of Infancy or Early Childhood, which was rarely used or studied. ARFID is described as substantial restrictions or challenges with food intake, associated with weight loss or lack of expected weight gain in the context of significant physiological and/or psychosocial distress. Drs. Katzman and Norris have led or participated in a variety of studies on the diagnosis since its introduction and are planning future studies in the area as well.
"ARFID is not just about picky eating - it's a very challenging diagnostic category in the DSM-5," says coauthor Dr. Debra Katzman, a Staff Physician in the Eating Disorders program and Senior Associate Scientist at SickKids. "These kids have complexity, and this condition persists for long periods of time and requires treatment to address both the medical and psychosocial aspects of the condition. If left untreated, children and teens may be left with serious, long-term complications."
In addition to the physiological impairments caused by the disorder, there are serious social implications, especially for teens, whose social interactions are often centred around food. "For those teens who are unable to go out to eat pizza with their friends, the condition can be socially limiting," says Katzman, who is also Professor of Paediatrics at the University of Toronto.
"Parents have a significant role in identifying unhealthy patterns in their child," says coauthor Dr. Mark Norris, Adolescent Health Physician and Associate Professor of Paediatrics within the Department of Pediatrics at CHEO. "Concerned parents should talk to their child's paediatrician or family doctor early on, rather than letting the problem persist for months or even years."
It is also critical, he explains, that clinicians on the front-lines and in eating disorders programs alike become more familiar with the diagnosis, so that the depth and range of eating difficulties among children, teens and adults can be further studied. In tandem, eating disorders specialists are working to assess outcomes and evaluate the effectiveness of different interventions.
ARFID - Fast Facts:
- ARFID is typically associated with other medical and psychiatric conditions, often including gastrointestinal conditions like inflammatory bowel disease, as well as anxiety disorders.
- The average time to diagnosis is 33 months.
- A higher proportion of diagnoses are made in boys than in anorexia nervosa; however, like most eating disorders, ARFID is more common in girls overall (70 per cent girls vs. 30 per cent boys).
- Without treatment, ARFID can cause a wide range of complications, including nutritional problems like iron-deficiency anemia and low bone-mineral density; delayed pubertal development; and problems with overall growth and development.
- Treatment protocols are still being developed, but current treatment includes outpatient family counseling, as well as exposure therapy, in which new foods are slowly and carefully introduced to the child, with appropriate supports in place.
- About 13 per cent of the patients seen in paediatric tertiary-care centres with eating disorders programs, like SickKids, are now diagnosed with ARFID.