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Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5

Open AccessPublished:February 06, 2014DOI:https://doi.org/10.1016/j.jadohealth.2013.11.013

      Abstract

      Purpose

      To evaluate the DSM-5 diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) in children and adolescents with poor eating not associated with body image concerns.

      Methods

      A retrospective case-control study of 8–18-year-olds, using a diagnostic algorithm, compared all cases with ARFID presenting to seven adolescent-medicine eating disorder programs in 2010 to a randomly selected sample with anorexia nervosa (AN) and bulimia nervosa (BN). Demographic and clinical information were recorded.

      Results

      Of 712 individuals studied, 98 (13.8%) met ARFID criteria. Patients with ARFID were younger than those with AN (n = 98) or BN (n = 66), (12.9 vs. 15.6 vs. 16.5 years), had longer durations of illness (33.3 vs. 14.5 vs. 23.5 months), were more likely to be male (29% vs. 15% vs. 6%), and had a percent median body weight intermediate between those with AN or BN (86.5 vs. 81.0 and 107.5). Patients with ARFID included those with selective (picky) eating since early childhood (28.7%); generalized anxiety (21.4%); gastrointestinal symptoms (19.4%); a history of vomiting/choking (13.2%); and food allergies (4.1%). Patients with ARFID were more likely to have a comorbid medical condition (55% vs. 10% vs. 11%) or anxiety disorder (58% vs. 35% vs. 33%) and were less likely to have a mood disorder (19% vs. 31% vs. 58%).

      Conclusions

      Patients with ARFID were demographically and clinically distinct from those with AN or BN. They were significantly underweight with a longer duration of illness and had a greater likelihood of comorbid medical and/or psychiatric symptoms.

      Keywords

      Implications and Contribution
      Adolescents with ARFID are demographically and clinically distinct from those with AN or BN. They are significantly underweight, often with associated medical and/or psychiatric symptoms. This report supports the potential clinical utility of ARFID and underlines the need for additional research to clarify course, outcome, and response to treatment.
      A significant number of children and adolescents who present with feeding or eating disorders cannot be classified using the DSM-IV criteria [
      • Peebles R.
      • Hardy K.K.
      • Wilson J.L.
      • Lock J.D.
      Are diagnostic criteria for eating disorders markers of medical severity?.
      ,
      American Psychiatric Association (APA)
      Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
      ,
      American Psychiatric Association (APA)
      Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).
      ]. Patients who did not meet the DSM-IV criteria for anorexia nervosa (AN) or bulimia nervosa (BN) were often given a diagnosis of eating disorder not otherwise specified (EDNOS). Using the DSM-IV, over 50% of children and adolescents with eating disorders were diagnosed with EDNOS [
      • Peebles R.
      • Hardy K.K.
      • Wilson J.L.
      • Lock J.D.
      Are diagnostic criteria for eating disorders markers of medical severity?.
      ]. Although these patients did not meet the DSM-IV criteria for a specific eating disorder, they experienced clinical impairment in development and function and were at risk for severe medical complications [
      • Peebles R.
      • Hardy K.K.
      • Wilson J.L.
      • Lock J.D.
      Are diagnostic criteria for eating disorders markers of medical severity?.
      ].
      EDNOS has been a heterogeneous category that includes a subset of patients who are, in general, younger than those with AN or BN and do not endorse significant body image distortion or a fear of weight gain [
      • Timimi S.
      • Douglas J.
      • Tsiftsopoulis K.
      Selective eaters: A retrospective case note study.
      ,
      • Nicholls D.
      • Chater R.
      • Lask B.
      Children into DSM don't go: A comparison of classification systems for eating disorders in childhood and early adolescence.
      ,
      • Peebles R.
      • Wilson J.L.
      • Lock J.D.
      How do children with eating disorders differ from adolescents with eating disorders at initial evaluation?.
      ,
      • Madden S.
      • Morris A.
      • Zrynski Y.A.
      • et al.
      Burden of eating disorders in 5–13-year-old children in Australia.
      ,
      • Nicholls D.E.
      • Lynn R.
      • Viner R.M.
      Childhood eating disorders: British national surveillance study.
      ,
      • Bryant-Waugh R.
      • Markham L.
      • Kreipe R.
      • Walsh B.T.
      Feeding and eating disorders in childhood.
      ]. Currently, there are no evidence-based studies describing this group of patients. Anecdotally, clinicians report that patients in this subset had experienced choking episodes or vomiting followed by the development of fear of eating solid foods, had restricted diets since early childhood, or had reported abdominal pain that had prevented them from eating sufficiently. The Great Ormond Street criteria for categorizing eating disorders in younger patients, including functional dysphagia, selective eating, and food-avoidance emotional disorder, were found to be more reliable, because these diagnostic categories captured the presentations of many of these children and adolescents [
      • Watkins B.
      • Lask B.
      Eating disorders in school-aged children.
      ].
      The DSM-5 Eating Disorder Work Group was charged with revising and updating the DSM-IV diagnostic criteria to provide clinical guidelines for clinicians caring for individuals with eating disorders, including such patients [
      • Bravender T.
      • Bryant-Waugh R.
      • Herzog D.
      • et al.
      Classification of child and adolescent eating disturbances. Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA).
      ,
      • Bravender T.
      • Bryant-Waugh R.
      • Herzog D.
      • et al.
      Classification of eating disturbance in children and adolescents: Proposed changes for the DSM-V.
      ]. This meant improving the definition of eating disorders in children and adolescents to reflect the clinical expression of these disorders across the developmental spectrum and lifespan. A specific goal of this work group was to examine the variety of clinical presentations of those patients who had been diagnosed with EDNOS, explore the clinical utility of the DSM-IV category of Feeding Disorder of Infancy or Early Childhood, and consider the variety of clinical presentations that did not fit into the existing categories in the DSM-IV (e.g., food-avoidance emotional disorder, selective eating). In keeping with this goal, the work group revised the DSM-IV diagnoses and combined the former sections “Eating Disorders” and “Feeding and Eating Disorders of Infancy or Early Childhood” into a single section, “Feeding and Eating Disorders,” with Avoidant/Restrictive Food Intake Disorder (ARFID) as a newly described diagnosis in this section (Table 1) [
      American Psychiatric Association (APA)
      Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
      ]. It was anticipated that the inclusion of ARFID as a diagnosis within Feeding and Eating Disorders in the DSM-5 would improve clinical utility and capture a population of young people who had an eating disorder, experienced medical and psychological morbidities, and who might otherwise be excluded from the DSM diagnostic criteria.
      Table 1DSM-5 diagnosis of Avoidant/Restrictive Food Intake Disorder
      American Psychiatric Association (APA)
      Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
      • A.
        An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
        • 1.
          Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
        • 2.
          Significant nutritional deficiency.
        • 3.
          Dependence on enteral feeding or oral nutritional supplements.
        • 4.
          Marked interference with psychosocial functioning.
      • B.
        The disturbance is not better explained by lack of available food or by associated culturally sanctioned practice.
      • C.
        The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced.
      • D.
        The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
      The purpose of this study was to describe the characteristics of children and adolescents presenting to seven adolescent-medicine eating disorder programs who met the DSM-5 criteria for ARFID and to compare them to patients meeting the DSM-5 criteria for AN and BN. The same seven eating disorder programs have recently published a paper demonstrating the general distribution of eating disorder diagnoses in children and adolescents using the DSM-5 criteria [
      • Ornstein R.M.
      • Rosen D.S.
      • Mammel K.A.
      • et al.
      Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders.
      ].

      Methods

      A retrospective chart review was completed on all new patients between 8 and 18 years of age who presented to seven adolescent-medicine eating disorder programs across the United States and Canada between January and December 2010. Patients with a diagnosis of ARFID were identified at each site using a diagnostic checklist based on the proposed DSM-5 diagnostic criteria. A table of random numbers was used to select an equal number of patients with AN and BN. Cases of AN and BN were identified based on DSM-5 criteria. At some sites, there were fewer patients seen with BN than with ARFID. Under these circumstances, all patients with BN were enrolled, resulting in fewer patients with BN than those with ARFID and AN.
      Data collected on all patients included age, gender, ethnicity, weight, and height. Additional clinical information included duration of illness, highest and lowest weights and body mass index (BMI) percentile, intake setting (out-patient vs. other), referral source, and presence of a medical condition, mood disorder, anxiety disorder, autism spectrum disorder, cognitive impairment, food allergies, a choking episode, difficulty swallowing, or sensory issues.
      The documented reason for poor nutritional intake in the ARFID group was also delineated, and included selective (picky) eating since early childhood, generalized anxiety, fear of vomiting or choking, gastrointestinal symptoms, food allergies, and “other” reasons.
      Data were entered into EXCEL, and analyzed in aggregate by one of the authors (B.T.W.). Chi-square analyses were used for categorical variables and ANOVA for continuous variables. Post-hoc testing was performed to assess statistical significance between ARFID and AN groups and between ARFID and BN groups when there was overall statistical significance. For post-hoc testing, Tukey's Honestly Significant Difference (HSD) was used for continuous variables and 2-by-2 Chi-square analysis with Bonferroni correction was used for categorical variables. Statistical analysis was conducted using Stata 12.1 (StataCorp LP, College Station, TX).
      Institutional review boards/research ethics boards at each of the participating study sites approved the study.

      Results

      A total of 712 new patients with eating disorders presented to the seven study sites during 2010. Of these, 98 patients (13.8%) met criteria for ARFID using DSM-5 criteria. The diagnosis of ARFID was fairly consistent across sites, with the exception of one site (University of Michigan). At six of the seven sites, the frequency of patients with ARFID ranged between 7.2% and 17.4%; however, the incidence at the remaining site was 41.0%. The number of patients who met DSM-5 criteria for AN and BN used in the analysis to compare with the patients with ARFID were 98 and 66, respectively.
      Characteristics of patients with ARFID, AN, and BN are summarized in Table 2. Almost 30% of patients with ARFID were male, a far higher percentage than those with either AN or BN. The percent median body weight (% MBW) for patients with ARFID (86.5) was between those with AN (81.0) and those with BN (107.5). Patients with ARFID tended to be younger and had a significantly longer duration of illness. The majority of all patients were evaluated as out-patients. Patients with ARFID were less likely to be self-referred. Although patients with ARFID were more likely to have a medical condition or an anxiety disorder than those with AN or BN, they were less likely to have a mood disorder.
      Table 2Clinical characteristics of patients with ARFID, anorexia nervosa, or bulimia nervosa
      ARFID (n = 98)Anorexia nervosa (n = 98)Bulimia nervosa (n = 66)
      Age (years)12.9 ± 2.515.6 ± 1.9
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      16.5 ± 1.3
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      F[2,259] = 71.2, p < .001
      % Median body weight86.5 ± 15.181.0 ± 9.2
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      107.5 ±16
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      F[2,259] = 80.8, p < .001
      Lowest weight (kg)35.0 ± 11.941.4 ± 7.3
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      53.3 ± 9.5
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      F[2,247] = 64.7, p < .001
      Highest weight (kg)40.8 ± 15.054.0 ± 12.9
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      65.0 ± 12.4
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      F[2,245] = 59.1, p < .001
      Duration (months)33.3 ± 41.314.5 ± 12.2
      Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      23.5 ± 17.1F[2,258] = 11.3, p < .001
      Gender
      Significant difference between anorexia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Significant difference between bulimia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Chi-square (df = 2) = 15.0, p < .001
       Female (%)71.385.794.0
       Male (%)28.614.36.0
      Intake settingChi-square (df = 2) = 5.6, p < .10
       OPD (%)87.785.797.0
       Other (%)12.314.33.0
      Referral source
      Significant difference between bulimia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Chi-square (df = 10) = 26.7, p < .01
       Self (%)6.210.215.5
       PCP (%)51.650.053.0
       Mental health (%)11.316.322.7
       Emergency department (%)10.311.24.6
       Social service (%)1.04.11.5
       Other (%)03.03.0
      Medical condition or symptom
      Significant difference between anorexia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Significant difference between bulimia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Chi-square (df = 14) = 54.4, < .001
       Yes, related (%)34.68.24.6
       Yes, unrelated (%)16.32.06.1
       None (%)49.189.889.3
      Mood disorder
      Significant difference between bulimia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Chi-square (df = 4) = 33.3, p < .001
       MDD/dysthymia (%)7.219.423.1
       Other (%)11.311.235.4
       None (%)81.569.441.5
      Anxiety disorder
      Significant difference between anorexia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Significant difference between bulimia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      Chi-square (df = 6) = 23.4, p < .001
       GAD (%)28.614.37.6
       OCD (%)6.18.21.5
       Other (%)23.513.324.2
       None (%)41.864.266.7
      ARFID = Avoidant/Restrictive Food Intake Disorder; GAD = generalized anxiety disorder; MDD = major depressive disorder; OCD = obsessive-compulsive disorder; OPD = out-patient department; PCP = primary care physician.
      a Significant difference from ARFID, p ≤ .05 by Tukey's Honestly Significant Difference (HSD).
      b Significant difference between anorexia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      c Significant difference between bulimia nervosa and ARFID by Chi-square, p < .05 after Bonferroni correction.
      The authors grouped the ARFID patients according to specific symptoms documented in the medical record. The groupings of the ARFID patients included 28 (28.7%) with selective (picky) eating since early childhood; 21 (21.4%) with generalized anxiety; 19 (19.4%) with gastrointestinal symptoms; 13 (13.1%) with fears of eating secondary to fears of choking or vomiting; 4 (4.1%) with food allergies; and 13 (13.2%) with restrictive eating for “other” reasons. There were no statistically significant differences by age or gender among the patients in these groups. Further, unlike the patients with ARFID, patients with AN and BN had almost none of the above associated symptoms.

      Discussion

      This is the first study to describe a large cohort of children and adolescents meeting the DSM-5 diagnostic criteria for ARFID. Approximately 14% of all new eating disorder patients who presented to seven adolescent-medicine eating disorders programs between January and December 2010 met these criteria.
      The diagnostic criteria for ARFID are broad. Bryant-Waugh has outlined a diagnostic checklist for criterion A of ARFID to facilitate gathering the appropriate information [
      • Bryant-Waugh R.
      Avoidant restrictive food intake disorder: An illustrative case example.
      ]. Despite the novelty of these criteria, clinicians who staffed programs focusing on eating disorders were able to utilize information in the medical records to make a diagnosis of ARFID in a substantial number of children and adolescents.
      This multicenter study revealed that all but one research site had a similar incidence of patients with ARFID, suggesting that the diagnosis of ARFID across sites was reliable and stable. The reasons for the difference in the frequency of ARFID at the one site are unclear. This site was known as a center that specialized in the care of younger patients with eating disorders. Therefore, a higher proportion of younger patients may have been directed to the site. However, all data were analyzed both including and excluding this site and no differences in statistical analyses were found.
      This retrospective study found that children and adolescents with ARFID were significantly different clinically from those with AN or BN. Although ARFID is a broad category that captures a range of clinical presentations, children and adolescents with this diagnosis were younger, had a longer duration of illness prior to diagnosis, and included a greater number of males than patients with AN or BN. In addition, although the % MBW for patients with ARFID was between those with AN and BN, the overall % MBW was still low. Clinicians should recognize that low % MBW may be a sign of an eating disorder. Further, clinicians should also be aware that weight loss and low % MBW may not only occur in patients with AN, but can also occur in children and adolescents with ARFID. Therefore, children and adolescents with ARFID should be assessed in a similar way as patients with AN because they are at risk for the same medical complications.
      Patients with ARFID were more likely to have a medical condition or symptom compared with patients with AN or BN. Further, patients with ARFID were significantly more likely to have an anxiety disorder than patients with AN or BN, but less likely to have depression.
      A large number of children and adolescents included in this group had an eating or feeding disturbance that was manifested by persistent failure to meet appropriate nutritional and/or energy needs and experienced significant associated physiological or psychosocial problems. Some data suggest that other disorders, such as anxiety disorders, obsessive-compulsive disorders, attention deficit disorders, and autism spectrum disorders, may be associated with ARFID [
      • Timimi S.
      • Douglas J.
      • Tsiftsopoulis K.
      Selective eaters: A retrospective case note study.
      ]. Although we identified children and adolescents with psychological disorders, we were unable to determine whether these should be considered risk factors for the development of ARFID. Many of the patients experienced generalized anxiety and gastrointestinal symptoms. Importantly, a diagnosis of ARFID was given only when the feeding disturbance itself caused significant clinical impairment that required intervention beyond what is usually required for the other condition.
      As this was a retrospective chart review, the course of the illness for these individuals is unknown. It is possible that these children and adolescents with ARFID could develop another eating disorder such as AN or BN. Further, it has been postulated that children and adolescents with ARFID may be at risk of impaired social functioning and family functioning, especially if there is great stress surrounding mealtimes. Further prospective and long-term follow-up studies are required.
      This study has several limitations. This was a cross-sectional retrospective chart review and relied on information that was available in existing medical records. In addition, there was no examination of the reliability of diagnostic assessment. However, in a field trial sponsored by the American Psychiatric Association prior to the publication of DSM-5, ARFID was found to have good reliability [
      • Regier D.
      • Narrow W.E.
      • Clarke D.E.
      • et al.
      DSM-5 field trials in the United States and Canada, Part II: Test-retest reliability of selected categorical diagnoses.
      ]. Finally, this study was performed in adolescent medicine tertiary care centers. For these reasons, care should be taken in generalizing results from this sample.
      This is the first multicenter study to support the identification of ARFID as a separate diagnostic group with unique clinical characteristics. Children and adolescents with ARFID were both demographically and clinically distinct from those with AN and BN. ARFID captures a subset of patients who have distinct clinical features who were either included among the heterogeneous group of EDNOS in DSM-IV or not recognized as having an eating disorder. Increasing recognition of children and adolescents with ARFID should occur with the clear articulation of the diagnostic criteria for this disorder outlined in the DSM-5. This will allow earlier access to care, with prompt identification and treatment of medical and psychiatric complications. The clinical utility of this unique diagnostic category and its relative prognostic and therapeutic implications are not known and require investigation. Nonetheless, recognition of ARFID in the DSM-5 will stimulate further research into its characteristics, and provide needed information on course, prognosis, and treatment approaches.

      Funding sources

      Sources of support: National Institute of Health (DKK), Canadian Institute of Health Research and Thrasher Foundation (DKK); Royalties from Wolters Kluwer/Lippincott, Williams & Wilkins (DKK); AstraZeneca (BTW).

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