Individuals with Avoidant Restrictive Food Intake Disorder (ARFID) exhibit food avoidance and restriction, often stemming from disinterest in food, sensory aversions, or fear of choking/vomiting (APA, 2013). Diagnosis involves ruling out other medical or mental conditions, cultural factors, or food availability issues.
ARFID’s prevalence parallels that of anorexia (Van Buuren et al., 2023), affecting 0.5-5.0% of children and adults in the general population (D’Adamo et al., 2023; Fitzsimmons-Craft et al., 2019; Kurz et al., 2015; Schmidt et al., 2018), and 1.5-64.0% within clinical eating disorder populations (Cooney et al., 2018; Fisher et al., 2014; Nicely et al., 2014).
While ARFID leads to weight-related, nutrient deficiency and psychosocial challenges, specific guidance for its treatment is limited. Current recommendations advocate for adapting interventions from other eating disorders (APA, 2013). Given ARFID’s unique features, its early onset, male predominance, and frequent comorbidity with anxiety, developmental, and learning disorders (Bourne et al., 2020; Fisher et al., 2014), there’s a pressing need for tailored treatment guidance.
This scoping review by Willmott et al. (2023) explores existing psychological interventions for ARFID, aiming to inform future research comparing their efficacy and suitability for different demographics, facilitating practical application.
ARFID involves avoidance and restriction of food. This is usually due to a lack of interest in food, aversion to specific sensory properties of food or concerns about choking and vomiting.
Methods
The authors pre-registered this review on the Open Science Framework Portal and adhered to PRISMA and Joanna Briggs institute guidelines for scoping reviews. Databases were searched for peer-reviewed studies in various therapeutic settings.
Included studies had to:
- Mention psychological interventions for ARFID
- Involve participants meeting ARFID criteria (e.g., DSM-IV or ICD-11 criteria, or according to psychiatric or psychological assessment)
- Utilise psychometric measures
- Be published in English and peer-reviewed journals
All study designs and participant age ranges were included. In contrast, review articles and studies that did not include psychological interventions were excluded.
Titles and abstracts were screened for relevance, before full-text eligibility was assessed in author pairs. Disagreements were resolved by a third researcher. A risk of bias assessment was not conducted, as it is not required in scoping reviews.
Results
Study and participant characteristic
50 studies were included in this scoping review. Most studies featured small sample sizes or single-case designs (n = 23) and were conducted in North America (70%) with predominantly White (82%) and high socio-economic status participants.
In terms of comorbidities, 38% of studies mentioned anxiety, 32% mentioned Autistic Spectrum Disorder (ASD), 20% mentioned developmental or intellectual disabilities, and 18% mentioned Attention Deficit Hyperactivity Disorder (ADHD).
Participant ages ranged from 13 months to 55 years, with 48% of studies involving mixed-sex populations and 84% focusing on child and adolescent populations.
Intervention types
Four types of interventions were identified:
- Mixed interventions (combining two or more of the other types of intervention; n = 19)
- Behavioural interventions (n = 16)
- Cognitive behavioural (CBT) interventions (n = 10)
- Family interventions (n = 5)
Behavioural interventions were commonly applied to those up to the age of 15 years old, with family therapy mostly used among those aged 21 years and younger. CBT was applied across the broadest age range. Interventions were delivered across inpatient, day treatment, outpatient, and virtual settings.
Intervention content
- Behavioural interventions typically used positive contingent reinforcement (providing praise or rewards for displaying the desired behaviour such as bites of food accepted), or differential reinforcement (e.g., giving attention to desired behaviour and ignoring undesirable behaviours).
- CBT interventions employed goal setting, graded/self-led exposure to avoided or unfamiliar foods, behavioural experiments, cognitive restructuring, anxiety management techniques and psychoeducation about physical sensations. These techniques aimed to reduce maintaining cognitions and behaviours related to ARFID (e.g., food avoidance, fears of interoceptive sensations or vomiting which may underly a limited diet).
- Family therapy interventions usually involved parents taking control of feeding and then gradually returning this to the adolescent. Parent skills training, psychoeducation, externalisation, and a focus on the family meal were also key features.
Many interventions used adjunctive treatments like medications, dietetic interventions, or speech therapy, affirming that support in these areas could be required to supplement and improve the accessibility of core treatment plans (Mairs & Nicholls, 2016; Thomas et al., 2017).
Intervention outcomes
Nearly all interventions demonstrated ARFID improvement, through increased food acceptance, changes in eating behaviours, reduced anxiety and depression scores, reduced inappropriate mealtime behaviours, and reduced ARFID symptoms (i.e., participants no longer meeting ARFID diagnosis criteria).
However, Body Mass Index (BMI), weight, and height were often used to measure ARFID improvement despite evidence that these physical metrics do not always indicate ARFID severity or recovery (Yule et al., 2021). Most studies lacked validated psychological measures, and measures specifically adapted for ARFID.
Most interventions for ARFID use physical outcomes (e.g., weight, height, menstruation status) to measure improvement, despite these often not accurately reflecting ARFID recovery.
Conclusions
This scoping review identified four ARFID intervention types, detailing key components and demographic differences in their application. Shared features across different intervention types included psychoeducation on ARFID, nutrition, and anxiety management, treatment generalisation, and family/caregiver involvement. This suggests these are important considerations regardless of the across therapeutic modalities of ARFID treatment.
Furthermore, all interventions yielded positive outcomes, but studies commonly used physical measures like BMI, weight, menstruation status, and blood test results as indicators, despite the fact that these measures may inadequately reflect ARFID improvement/recovery.
Across all types of intervention, the involvement of family and caregivers in treatment was a key theme, highlighting its potential importance in the development of future ARFID interventions.
Strengths and limitations
One strength of this study was its adherence to scoping review guidelines, and pre-registration on the Open Science Framework Portal. This makes it easy to replicate the study to verify findings and adds to the transparency and credibility of results.
However, as this review adhered to standard scoping review guidelines which do not necessitate an assessment of study bias, it is difficult to ascertain whether the studies included in the review contained reliable, high-quality information. This makes conclusions about the types of interventions used to treat ARFID, and their typical outcome measures slightly more tentative.
Also, due to the dearth of literature on ARFID, this review included many studies using a small number of participants, and unstandardised, unvalidated outcome measures for ARFID improvement. This means that whilst the study was able to identify different ARFID interventions and outcomes, these findings may not be reliable.
Last, the authors note that when selecting studies, they excluded potentially relevant literature mentioning interventions for paediatric feeding disorders but not ARFID. This suggests a need to compare ARFID interventions with other eating and feeding disorders to determine to what extent interventions for other eating disorders might provide insights for ARFID treatment.
Many of the studies included in this scoping review were single-case studies or involved a small number of participants, causing concern regarding the reliability of findings.
Implications for practice
This scoping review highlights the need to develop standardised psychological measures for ARFID improvement and a coherent definition of ‘ARFID recovery’. This would enable researchers to properly compare and quantify the efficacy of different interventions, so that the effective ones can be applied in practice. Relatedly, high-powered randomised control studies on ARFID interventions, which are currently lacking, would also help to rigorously test the efficacy of different ARFID interventions. These studies would also enable a meta-analysis which could validate suggestions from this review that certain considerations (e.g., family involvement) may be important in ARFID treatment regardless of the therapeutic modality used.
Future research should also compare the efficacy of interventions across different ages, populations and comorbidities to develop more specific guidance regarding the suitability of different interventions for different groups of ARFID patients, as guidance in this area is currently lacking. For example, as mentioned by the authors, limited research on ARFID interventions in non-White, non-Western populations raises questions about cultural differences in the efficacy of and suitability of different ARFID interventions. The scoping review also suggests that behavioural therapy is more often applied to younger children, perhaps due to their developmental immaturity for other therapeutic techniques (Frankel et al., 2012), whilst CBT may have suitability across a broader age-span, which should be investigated further.
Whilst this scoping review identified four different types of interventions currently being used in ARFID treatment, adequately powered high-quality randomised controlled trials are needed to determine effectiveness.
Statement of interests
The author of this blog declares that they have no competing interests or conflicts of interest in relation to the subject of this study.
Links
Primary paper
Willmott, E., Dickinson, R., Hall, C., Sadikovic, K., Wadhera, E., Micali, N., . . . Jewell, T. (2023). A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID). International Journal of Eating Disorders.
Other references
American Psychiatric Association [APA] (2013). Diagnostic and statistical manual of mental disorders. The American Psychiatric Association.
Bourne, L., Bryant-Waugh, R., Cook, J., & Mandy, W. (2020). Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature. Psychiatry Research, 288, 112961.
Cooney, M., Lieberman, M., Guimond, T., & Katzman, D. K. (2018). Clinical and psychological features of children and adolescents diagnosed with avoidant/restrictive food intake disorder in a pediatric tertiary care eating disorder program: a descriptive study. Journal of Eating Disorders, 6(1), 1-8.
D’Adamo, L., Smolar, L., Balantekin, K. N., Taylor, C. B., Wilfley, D. E., & Fitzsimmons-Craft, E. E. (2023). Prevalence, characteristics, and correlates of probable avoidant/restrictive food intake disorder among adult respondents to the National Eating Disorders Association online screen: a cross-sectional study. Journal of Eating Disorders, 11(1), 214.
Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., . . . Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. Journal of Adolescent Health, 55(1), 49-52.
Fitzsimmons‐Craft, E. E., Balantekin, K. N., Graham, A. K., Smolar, L., Park, D., Mysko, C., . . . Wilfley, D. E. (2019). Results of disseminating an online screen for eating disorders across the US: Reach, respondent characteristics, and unmet treatment need. International Journal of Eating Disorders, 52(6), 721-729.
Frankel, S. A., Gallerani, C. M., & Garber, J. (2012). Developmental considerations across childhood. In E. Szigethy, J. R. Weisz, & R. L. Findling (Eds.) Cognitive-behavior therapy for children and adolescents (pp. 29-73). American Psychiatric Publishing Inc.
Kurz, S., Van Dyck, Z., Dremmel, D., Munsch, S., & Hilbert, A. (2015). Early-onset restrictive eating disturbances in primary school boys and girls. European Child & Adolescent Psychiatry, 24, 779-785.
Mairs, R., & Nicholls, D. (2016). Assessment and treatment of eating disorders in children and adolescents. Archives of Disease in Childhood, 101(12), 1168-1175.
Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). 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, 2(1), 1-8.
Schmidt, R., Vogel, M., Hiemisch, A., Kiess, W., & Hilbert, A. (2018). Pathological and non-pathological variants of restrictive eating behaviors in middle childhood: A latent class analysis. Appetite, 127, 257-265.
Thomas, J. J., Lawson, E. A., Micali, N., Misra, M., Deckersbach, T., & Eddy, K. T. (2017). Avoidant/restrictive food intake disorder: a three-dimensional model of neurobiology with implications for etiology and treatment. Current Psychiatry Reports, 19, 1-9.
Van Buuren, L., Fleming, C. A. K., Hay, P., Bussey, K., Trompeter, N., Lonergan, A., & Mitchison, D. (2023). The prevalence and burden of avoidant/restrictive food intake disorder (ARFID) in a general adolescent population. Journal of Eating Disorders, 11(1), 104.
Yule, S., Wanik, J., Holm, E. M., Bruder, M. B., Shanley, E., Sherman, C. Q., . . . Parenchuck, N. (2021). Nutritional deficiency disease secondary to ARFID symptoms associated with autism and the broad autism phenotype: a qualitative systematic review of case reports and case series. Journal of the Academy of Nutrition and Dietetics, 121(3), 467-492.
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