Part Four A: UCSD EDC2014 Review
Is it an Eating Disorder or what? Children with Gastrointestinal Symptoms or Avoidant-Restrictive Food Intake Disorder.
ARFID (technically A/RFID). That is just an unattractive acronym to pronounce out loud isn’t it? It was the topic under review before our lunch break on the first day of the UCSD EDC2014 conference.
Drs. Jessie Menzel and Rebecca Bernard captured the essence of this new DSM classification: “Is it an eating disorder or what?” It’s avoidant/restrictive food intake disorder.
I’m going to break out their talk into two installments (A and B) as there is a lot of ground to cover off that will likely be of interest to the readership here.
Dr. Menzel began the presentation by walking us through the diagnostic features, treatment approaches.
We first took a look at the DSM definition, as follows:
An eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following:
A. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
B. Significant nutritional deficiency.
C. Dependence on enteral feeding or oral nutritional supplements.
D. Marked interference with psychosocial functioning.
B. Disturbance not better explained by lack of available food or a culturally sanctioned practice.
C. Does not occur exclusively during the course of another eating disorder and there is no evidence of a disturbance in body weight or shape.
D. Not attributable to another mental disorder or medical condition.
Picky-Eating
We’ve actually been discussing picky-eating or selective eating disorder on the forums since about 2012. A/RFID is essentially picky-eating. I’ll just extricate some of the information I’ve already posted in the forums on this topic here as a refresher:
It is sometimes referred to as selective eating disorder and it shows up pretty much from birth.
While it is clearly linked to all other facets of the eating disorder spectrum, it is distinct in that it appears very early on in life and it can remain a self-contained behavior that does not actually impact health or longevity in the way that all the other facets of restrictive eating can do.
Lifelong picky-eaters who do not develop an eating disorder do not appear to have nutritional deficits or health concerns as happens almost automatically with the other facets of eating disorders. [1] Julie O'Toole in her book Give Food A Chance speaks of one case study in the later chapters in her book regarding picky-eating that talks about this distinctness.
It’s interesting to note that the new ARFID checklist requires “significant nutritional deficiency” considering that the clinical data to suggest nutritional deficiency in the presence of picky-eating/ARFID is far from definitive at this point. A rather limited trial suggests that mothers consuming more fruits and vegetables were less likely to pressure their daughters to eat and had daughters who were less picky. Picky eaters consumed fewer fruits, vegetables, fats and sweets. All daughters consumed low amounts of vitamin E, calcium and magnesium but picky-eaters were at risk for not meeting recommendations for vitamin E and C and consumed significantly less fibre. [2] However actual nutritional deficiency is not confirmed by dint of not meeting recommended daily allowances.
Picky-eating goes back to sucking behaviours at birth even, so it's distinct from general conservative attitudes towards food (food neophobia) that most kids have and that lessen naturally as the child ages. Picky-eaters have fewer sucks per feeding session at weeks two and four when compared to healthy controls. [3]
Picky-eating and digestive problems are two precursors to the development of anorexia nervosa in later life. [4] However, like many things to do with genetic predispositions, a predisposition is never an absolute outcome.
Then there is a complex interplay between a parent with an active eating disorder and his or her child as well (I cover some of this off in the post on Reproductive Health Part One and I discuss underfeeding your child as a completely unconscious aspect of not being in remission near the end of that post).
Whenever I broach this topic, I always strongly reinforce the fact that no parent dealing with an eating disorder ever purposefully restricts their child's food intake— this behaviour is not due to induced-illness syndrome (formerly known as Munchausen's by proxy) at all. However, the anxiety you may have around food is never invisible to the child even if you do not let any comment slip out.
So while picky-eating in childhood is a risk factor for developing a full-on eating disorder as the child reaches adolescence, not all picky-eaters do develop an eating disorder.
While all children are neophobic with food choice, picky-eating involves a very limited number of foods the child will eat. Whereas the usual conservative child will taste a strange new food if she has been exposed to it showing up on her plate several times, a picky-eater simply will not. The neophobic response to food is, of course, a good survival instinct. You don't want hunter/gatherer kids deciding that random berries are worth a taste. But for those with picky-eating the threat response is too twitchy. Like many of these conditions, it's a spectrum that arises out of normal behaviour and has to be identified by uncovering its frequency and intensity, as well as determining its negative impact on quality of life.
“Picky eaters ate fewer foods and were especially more likely to avoid vegetables. Picky girls decreased their caloric intake between ages 3.5 and 5.5, whereas all other children increased their caloric intake…Picky eaters demonstrated a different sucking pattern with fewer sucks per feeding session at weeks 2 and 4. Finally, picky children displayed more parent-reported negative affect than nonpicky children.”
A/RFID
Dr. Menzel confirmed that the primary symptom of ARFID is a restricted range of foods. Limitations might be based on brand, texture, color, temperature and taste. As examples of these restrictions, the child might only eat food from Wendy’s, or foods that are soft, white, hot, or bland. Other features will include a slower rate of eating, smaller portions, showing a lack of interest in food, and greater struggles around food.
Presumably more boys are diagnosed with ARFID than girls, however I often find that any sexual differentiation in diagnosis reflects the inherent bias that originates within the DSM checklists and does not necessarily reflect the incidence of the underlying neurobiological predisposition (which are more likely to be equivalent between the sexes as these conditions are not defined by dominant lone-gene determinants).
In a very interesting review on food neophobia and picky/fussy eating in children (well worth a read actually), the authors discuss all the facets of food neophobia along with social facilitation and influence and had this to say:
“One contentious aspect of the social influences on food neophobia is that of sex. Some researchers have suggested that girls respond more to social pressures and peer models than boys. However, others have found no differences. This sex difference would make theoretical sense, as it has been demonstrated that girls, on average, develop more complex social interaction awareness skills earlier than boys, although inconsistencies are available within developmental studies too. Moreover, boys have higher tendencies to reject others’ opinions and ideas. Condensed down, this would point to a role of sex in changing food neophobia through social facilitation. By adolescence though this difference is not present, suggesting that boys have caught up on social awareness and are equally responsive to peer pressure and social influence in terms of overcoming food neophobia.”
It might therefore be possible that the tendency to resist social influence for pre-pubescent boys may account for the higher proportion of boys diagnosed with ARFID.
In any case, the quick review of data by Dr. Menzel revealed that ARFID impacts patients at a younger age than for other eating disorders. There is a longer duration of illness and a higher proportion of males when compare to other eating disorders. There is a high rate of comorbid anxiety disorders (up to 75%) and equally high rates of comorbid medical conditions (55%). [7],[8]
The common presentation of ARFID that the patient is a long standing picky eater; generalized anxiety disorder is often also present; there are gastrointestinal complaints; and to a lesser degree there can be vomiting/choking phobias or food allergies present. [9]
Common Interventions
Often parental reaction to avoidant and restrictive food behaviours inadvertently reinforces the behaviours. Understandably, to keep the peace, parents will often simply remove the unacceptable food in favour of providing the child with his preferred food.
The multi-component approach involves positive reinforcement and escape extinction. The positive reinforcement is to give the child the preferred stimuli (food, toys, praise, tokens) for a desired eating behaviour (accepting and swallowing bites). Escape extinction means that the child is no longer able to escape or avoid the food in question. That can mean the spoon sits in front of the child’s face until such time as he takes a bite. Not surprisingly, escape extinction tends to trigger extinction-induced aggression, outbursts and it becomes pretty miserable for the caregiver to physically prevent escape.
Dr. Menzel highlighted that several approaches that avoid escape extinction: differential reinforcement, continuous reinforcement and simultaneous presentation.
Differential reinforcement is when the preferred stimulus is contingent on achieving the desired behavior. So the preferred foods or drinks are on hand and used as positive reinforcement when a desired behavior is achieved. Continuous reinforcement is providing a non-contingent preferred stimulus continuously throughout the meal. An example provided in the literature for this was to have the child’s favourite video playing while he ate the non-preferred food. Simultaneous presentation means mixing the preferred and non-preferred foods together. [10]
Dr. Menzel did point out that picky eating is a relatively normal phenomenon (food neophobia in children is a clear survival trait). Picky eaters of normal weight do follow appropriate growth trajectories and they are not necessarily more nutritionally deficient than non-picky eaters. They are however at greater risk for being underweight and that leads to complications similar to what is seen in patients with anorexia nervosa.[11],[12],[13],[14]
Treating long standing picky eating involves a hierarchy of needs where restoring weight is paramount. Family-based treatment with psychoeducational guidance so that parents might manage mealtime behavior with various strategies and any nutritional deficiencies (supported with multivitamins) take precedence over adding new foods. Eventually new foods are added, when patient is highly motivated and a hierarchy of foods can guide expansion in a staged approach.
If generalized anxiety and food-related phobias are present, then the weight loss is presumed to be a by-product of the emotional disturbance. Treatment follows the family-based cognitive behavioural therapy model for other anxiety disorders. The primary goal is to treat the anxiety prior to or simultaneously while restoring weight and nutritional status.
Given that an eating disorder is an anxiety disorder— a misidentification of food as a threat— I personally would not make any particular distinction of comorbidities for various types of anxiety presenting alongside an eating disorder. I align closely with Dr. Tom Hildebrandt and colleagues’ assessment as follows:
“Although FBT [family-based treatment] has long been atheoretical, we propose that exposure and habituation to food, eating and related triggers are a primary mechanism of change. This would be evident with decreased anxiety in response to anxious stimuli and elimination of avoidance behaviours present in AN. This hypothesis is based on the overlap between EXRP [exposure and response prevention] and FBT for AN, as well as the similarities between AN and the anxiety disorders, both in symptom presentation and aetiological factors. Clinically, it has been observed that FBT is akin to parent-facilitated exposure in a real-world setting, with the primary stimuli being food and eating, although rituals and related anxious stimuli are also targeted. FBT directly addresses avoidance behaviours.”
Whether the avoidant food behaviours go back to picky-eating due to poor suck reflexes at birth; or develop from traumatic experience (stomach flu, choking incident); or coexist with several distinct phobias, generalized anxiety, social anxiety, or panic; or whether the avoidant behaviours are sustained or attenuated due to family interactions up to the point at which the patient seeks treatment; extinguishing avoidant food behaviours remains a dominant focus.
And as Dr. Menzel concluded, treating food-related phobias involves education for the parents and patient; exposure to the food and response prevention with guided post-exposure processing; and differential reinforcements for children: completing the food exposure and applying relaxation techniques throughout.
AJ Mascola, SW Bryson, WS Agras, Picky eating during childhood: A longitudinal study to age 11years." Eating behaviors, Vol.11(4), pp.253-257, 2010.
AT Galloway, L Fiorito, Y Lee, LL Birch, Parental pressure, dietary patterns, and weight status among girls who are “picky eaters”, Journal of the American Dietetic Association, Vol.105(4), pp.541-548, 2005.
CW Jacobi, WS Agras, S Bryson, LD Hammer, Behavioral validation, precursors, and concomitants of picky eating in childhood, Journal of the American Academy of Child & Adolescent Psychiatry, Vol.42(1), pp.76-84, 2003.
M Marchi, P Cohen, Early childhood eating behaviors and adolescent eating disorders, Journal of the American Academy of Child & Adolescent Psychiatry, Vol.29(1), pp.112-117, 1990.
CW Jacobi, WS Agras, S Bryson, LD Hammer, Behavioral validation, precursors, and concomitants of picky eating in childhood, Journal of the American Academy of Child & Adolescent Psychiatry, Vol.42(1), pp.76-84, 2003.
TM Dovey, PA Staples, EL Gibson, JCG Halford, Food neophobia and ‘picky/fussy’eating in children: A review, Appetite, Vol.50(2), pp.181-193, 2008.
RM Ornstein, DS Rosen, KA Mammel, ST Callahan, S Forman, MS Jay, M Fisher, E Rome, BT Walsh, Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders, Journal of Adolescent Health, Vol.53(2), pp.303-305, 2013.
TA Nicely, S Lane-Loney, E Masciulli, CS Hollenbeak, RM Ornstein, Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders, Journal of eating disorders, Vol.2(1), p.21, 2014.
RM Ornstein, DS Rosen, KA Mammel, ST Callahan, S Forman, MS Jay, M Fisher, E Rome, BT Walsh, Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders, Journal of Adolescent Health, Vol.53(2), pp.303-305, 2013.
MH Bachmeyer, Treatment of selective and inadequate food intake in children: A review and practical guide, Behavior analysis in practice, Vol.2(1), p.43, 2009.
KC Eckstein, LM Mikhail, AJ Ariza, JS Thomson, SC Millard, HJ Binns, Parents' perceptions of their child's weight and health, Pediatrics, Vol.117(3), pp.681-690, 2006.
AT Galloway, L Fiorito, Y Lee, LL Birch, Parental pressure, dietary patterns, and weight status among girls who are “picky eaters”, Journal of the American Dietetic Association, Vol.105(4), pp.541-548, 2005
AJ Mascola, SW Bryson, WS Agras, Picky eating during childhood: A longitudinal study to age 11years." Eating behaviors, Vol.11(4), pp.253-257, 2010.
ML Norris, A Robinson, N Obeid, M Harrison, W Spettigue, K Henderson, Exploring avoidant/restrictive food intake disorder in eating disordered patients: A descriptive study, International Journal of Eating Disorders, 2013.
T Hildebrandt, T Bacow, M Markella, KL Loeb, Anxiety in anorexia nervosa and its management using family‐based treatment, European Eating Disorders Review, Vol.20(1), pp. e1-e16, 2012.
