An ARFID case report combining family-based treatment with the unified protocol for Transdiagnostic treatment of emotional disorders in children

Development of an inpatient protocol for adolescents with avoidant/restrictive food intake disorder: a case study

Introduction

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder characterised by a pattern of eating that leads to failure to meet appropriate nutritional and/or energy needs.

Method

In the absence of evidence-based inpatient guidelines for adolescents with ARFID, we set out to develop and pilot an inpatient protocol for adolescents with ARFID. Identification of the key differences between managing inpatients with ARFID and anorexia nervosa (AN) led to modification of an existing AN protocol with the goals of better meeting patient needs, enhancing alignment with outpatient care, and improving outcomes. A case report of an adolescent with ARFID who had three hospital admissions is presented to highlight these changes. Interviews with this patient and her family were undertaken, together with key staff, to explore the challenges of the AN protocol for this patient and the perceived benefits and any limitations of the ARFID protocol for this patient and others.

Results

The new ARFID protocol supports greater choice of meals, without the need for rest periods after meals and bathroom supervision. The similarities with the AN protocol reflect the need to promote timely weight gain through meal support, including a staged approach to nutritional supplementation. The protocol appears to have been well accepted by the patient and her family, as well as by staff, and continues to be used in cases of ARFID.

Conclusion

Further evaluation would help identify how well this protocol meets the needs of different adolescents with ARFID.

A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID)

OBJECTIVE

This scoping review identifies and describes psychological interventions for avoidant restrictive food intake disorder (ARFID) and summarizes how outcomes are measured across such interventions.

METHOD

Five databases (Cochrane, Embase, Medline, PsycInfo, Web of Science) were searched up to December 22, 2022. Studies were included if they reported on psychological interventions for ARFID. Studies were excluded if participants did not have an ARFID diagnosis and if psychological interventions were not delivered or detailed.

RESULTS

Fifty studies met inclusion criteria; almost half were single-case study designs (23 studies) and most studies reported on psychological interventions for children and adolescents with ARFID (42 studies). Behavioral interventions (16 studies), cognitive-behavioral therapy (10 studies), and family therapy (5 studies), or combinations of these therapeutic approaches (19 studies) were delivered to support patients with ARFID. Many studies lacked validated measures, with outcomes most commonly assessed via physical health metrics such as weight.

DISCUSSION

This review provides a comprehensive summary of psychological interventions for ARFID since its introduction to the DSM-5. Across a range of psychological interventions and modalities for ARFID, there were common treatment components such as food exposure, psychoeducation, anxiety management, and family involvement. Currently, studies reporting on psychological interventions for ARFID are characterized by small samples and high levels of heterogeneity, including in how outcomes are measured. Based on reviewed studies, we outline suggestions for clinical practice and future research.

PUBLIC SIGNIFICANCE

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by avoidance or restriction of food due to fear, sensory sensitivities, and/or a lack of interest in food. We reviewed the literature on psychological interventions for ARFID and the outcomes used to measure change. Several psychological interventions have been developed and applied to patients with ARFID. Outcome measurement varies widely and requires further development and greater consensus.

Transdiagnostic Cognitive Behavioral Psychotherapy: Unified Protocol as an Example

The fact that there are many limitations of the current classification systems led to the emergence of transdiagnostic approaches (TA) that focus on the common psychopathological processes underlying disorders rather than categorical diagnoses. TA focuses on the underlying common psychopathological processes in the emergence and persistence of mental disorders. Thus, even if the disorders are categorically diagnosed differently, it can be determined how they overlap or separate with each other. TA aims to treat mental disorders using these aspects. TA has a flexible and modular structure that can be easily integrated into cognitive behavioral therapies. The rest of this review will focus on the Unified Protocol (UP), one of the most popular TA examples. The main purpose of the UP is to enable patients to recognize their feelings and give more adaptive reactions to their negative emotions. Accordingly, UP consists of eight modules. The modules can usually be completed in a total of 11 - 17 weeks. Each 50 to 60-minute individual session is held once a week. If necessary, changes can be made to the number or the frequency of sessions allocated to modules. The goals of each module of the UP and the treatment approaches towards these goals allow a very clearly defined approach. For this reason, there is a need for a detailed evaluation, conceptualization and treatment plan before the UP is put into practice. We hope that mental health professionals from Turkey will contribute to the developments in the UP.

Assessment and Treatment of Avoidant/Restrictive Food Intake Disorder

PURPOSE OF REVIEW

To review the literature pertaining to the assessment and treatment of avoidant/restrictive food intake disorder (ARFID) ten years following its introduction to DSM-5.

RECENT FINDINGS

Several structured clinical interviews for assessing ARFID have been developed, each with its own strengths and limitations. There is no clear leading self-report measure for tracking treatment progress and outcome in ARFID. Medical assessment is comprised of examining anthropometrics, vitamin deficiencies, and other comorbidities. To date, several studies have reported on cognitive behavioral therapy, family-based treatment, and other approaches to the treatment of ARFID. These treatments appear promising; however, they rely on data from clinical case series and very small randomized controlled trials. Several promising assessments and treatments for ARFID are in the early stages of research. Yet, controversies remain. These include (a) overlap with criteria for pediatric feeding disorder; (b) the optimal method for assessing nutrient deficiencies; (c) disciplines involved in treatment. Future research innovation is necessary to improve the psychometric properties of ARFID assessments and evaluate treatment efficacy with larger samples and randomized designs.

Cognitive behaviour therapy (CBT) as a psychological intervention in the treatment of ARFID for children and young people

Avoidant Restrictive Food Intake Disorder (ARFID) is a condition characterised by a disturbance in eating behaviour that leads to a significant negative impact on physical, social and nutritional health. The diagnosis of ARFID relies on a comprehensive, multi-disciplinary assessment to understand the individual’s history, physical, social and mental health risk, and any co-occurring mental health difficulties. Consensus guidance suggests that psychological treatment, alongside medical and dietetic input is delivered with consideration of any appropriate adaptions to accommodate developmental stage and/or common co-occurring presentations. This paper has been authored by clinicians working in an out-patient setting for children and adolescents with ARFID, and focuses on the presentation and assessment of ARFID and cognitive behavioural therapy (CBT) approaches that can help children, young people and their families. After an introductory section, the paper is split into four sections: assessment of ARFID; drivers of avoidant restrictive eating behaviour; multi-disciplinary formulation and intervention planning; and treatment. The treatment section provides an overview of the available research on CBT for ARFID, and a brief summary of the broader evidence base for CBT in children and young people with anxiety. Following a review of the evidence base, three case descriptions are provided to illustrate the clinical application of CBT where fear-based avoidance is the main driver. The paper concludes with practice points for clinicians to take forward when working with children and young people with ARFID.

Key learning aims

(1)

A Retrospective Literature Review of Eating Disorder Research (1990–2021): Application of Bibliometrics and Topical Trends

Despite the growing importance of eating disorders in society and academic literature, only a few bibliometric review studies using bibliometric analysis were available. Hence, this study aimed to explore and uncover hidden research topics and patterns in articles in terms of eating disorders over the last 30 years. In total, 4111 articles on eating disorders were analyzed using bibliometrics, network analyses, and structural topic modeling as the basis of mixed methods. In addition to general statistics about the journal, several key research topics, such as eating disorder (ED) treatment, ED symptoms, factors triggering ED, family related factors, eating behaviors, and social factors, were found based on topic correlations. This study found the key research variables that are frequently studied with EDs, such as AN, BN, BED, and ARFID. This study may help clinicians comprehend important risk factors associated with EDs. Moreover, the findings about key ED research topics and their association can be helpful for future studies to construct a comprehensive ED research framework. To our knowledge, this is the first study to use topic modeling in an academic journal on EDs and examine the diversity in ED research over 30 years of published research.

The efficacy of transdiagnostic cognitive behavioural therapy on reducing negative affect, anxiety sensitivity and improving perceived control in children with emotional disorders - a randomized controlled trial

In response to the high rate of comorbidity among different types of emotional disorders in children, Transdiagnostic Unified Protocol of Emotional disorder in children (UP-C) was developed to address common underlying mechanisms in the development and maintenance of emotional disorders using empirically supported cognitive and behavioural strategies. Although, studies supported the effectiveness of this protocol in the treatment of wide range of emotional disorders, further studies are needed to examine its effect on transdiagnostic factors. The present study aimed to investigate the efficacy of the UP-C on negative affect, anxiety sensitivity and perceived control in children with emotional disorders. During this randomized controlled trial, 34 children aged 7 to 13 with emotional disorders were randomly assigned to treatment (n=18) and control (n=16) groups. The treatment group and their parents received 15 sessions of UP-C. Negative Affect Schedule for Children (PANASNA- C), Children’s Anxiety Sensitivity Index (CASI), Anxiety Control Questionnaire-Children (ACQ-C) were carried out in all phases (pre-treatment, post-treatment, 3 and 8 months follow- up). The results showed that following UP-C, negative affect (hedges’g=2.01) and anxiety sensitivity (hedges’g=1.05) were significantly reduced, and perceived control (hedges’g= –2.36) was significantly improved. The results remained relatively constant during the follow-ups. Findings provide evidence that the UP-C has significant effect on negative affect, anxiety sensitivity and perceived control as roots of emotional disorders.

Widening the reach of family-based interventions for Anorexia Nervosa: autism-adaptations for children and adolescents

Family-based interventions are widely recommended as a first line treatment for children and young people with Anorexia Nervosa. There is clear evidence that model-adherent delivery of specific eating disorder focused family interventions has the potential to help adolescents with Anorexia Nervosa, who have typically engaged in extreme dietary restriction and lost a significant amount of weight over a relatively short period of time. Nevertheless, there remains a significant number of young people with restrictive eating disorders for whom family-based interventions for Anorexia Nervosa prove less effective, suggesting adaptations may be indicated for some. In this paper we provide a rationale and structure for considering a number of possible adaptations to the delivery of family-based therapy for anorexia nervosa specifically intended to enhance its relevance and potential effectiveness for children and adolescents on the autism spectrum; a subgroup known to represent a significant minority in eating disorder populations who have been identified as having relatively poor outcomes. Past research has shown that certain family-based treatments are effective for many children and adolescents who develop Anorexia Nervosa. At the same time this type of treatment approach in its current form does not work for everyone. Recent research has highlighted the overlap between anorexia and autism and the need for the development of adaptations to existing treatments to better meet the requirements of people on the autism spectrum who develop anorexia. With this in mind we propose a number of autism-related adaptations that could be made to family-based treatments for anorexia. We hope that these might be formally tested in the future to see if these adaptations improve outcomes for this group of individuals.

Case Presentations Combining Family-Based Treatment with the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents for Comorbid Avoidant Restrictive Food Intake Disorder and Autism Spectrum Disorder

Avoidant Restrictive Food Intake Disorder (ARFID) is a Feeding and Eating Disorder newly added to the Diagnostic and Statistical Manual of Mental Disorders, 5 ^th Edition, which presents with high prevalence rates in community and clinical settings. Given its recent diagnostic recognition, validated and standardized treatments for this population are lacking. In addition, given the complexity, heterogeneity of symptoms, and high rates of psychiatric comorbidities in the ARFID population, new models of care are required. The current therapy model combines two evidence-based treatments - Family Based Treatment (FBT) and the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A) - for young patients with ARFID plus Autism Spectrum Disorder (ASD), which allows clinicians to personalize care based on each patient's unique presenting needs. This paper presents two distinct cases which showcase the use of the FBT+UP for ARFID approach for treating comorbid ARFID and ASD in a clinical setting. Case 1 demonstrates the application and reliance on FBT, while Case 2 draws upon UP to facilitate behavioural change in the patient. Case backgrounds, presenting problems, and treatment approaches combining the two evidence-based treatments are presented and discussed. The cases demonstrate the unique challenges of treating young patients with comorbid ARFID and ASD, along with the proposed benefits of the combined approach with this population.

Multimodal therapy for rigid, persistent avoidant/restrictive food intake disorder (ARFID) since infancy: A case report

Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder that results in nutritional inadequacies, weight loss, and/or dependence on enteral feeds, and for which three clinical subtypes have been described. We present a unique case of an 11-year-old boy with rigid ARFID since infancy and features of all three ARFID subtypes. The patient presented with a life-long history of sensory aversion, limited intake and phobia of vomiting resulting in restriction to a single food item (yogurt) for more than 5 years. He presented with severe iron-deficiency anaemia, and deficiencies of vitamins A, C, D, E and zinc. We employed a multimodal therapeutic approach that incorporated elements of cognitive-behavioural therapy (CBT), family-based therapy (FBT) and pharmacological management with an antidepressant medication (sertraline) and an atypical antipsychotic agent (olanzapine). Over the course of a 7-week admission, our approach assisted the patient in successful weight restoration and incorporation of at least three new food items into his daily diet. While there are currently no first-line recommendations for ARFID management, our study lends support to the efficacy of CBT, FBT and pharmacological management for ARFID patients, including complex cases with multiple subtype features. Further research is needed to strengthen ARFID clinical guidelines.

SPACE-ARFID: A pilot trial of a novel parent-based treatment for avoidant/restrictive food intake disorder

OBJECTIVE

This pilot trial aimed to assess the feasibility, acceptability, treatment-satisfaction, and preliminary efficacy of Supportive Parenting for Anxious Childhood Emotions adapted for avoidant/restrictive food intake disorder (SPACE-ARFID). SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits and aims to promote food-related flexibility.

METHOD

Parents of 15 children (ages 6-14 years) with ARFID participated in 12 weekly sessions of SPACE-ARFID. Feasibility and acceptability were assessed by calculating enrollment, attendance, attrition, and adverse events. Treatment-satisfaction was assessed with the Client Satisfaction Questionnaire (CSQ-8), administered posttreatment. ARFID symptom severity and impairment and family accommodation were assessed at baseline and posttreatment.

RESULTS

Of 17 eligible families, 15 (88.24%) elected to participate in the trial. Of the 15 participating families, all except for 1 (6.67%) completed all 12 weekly treatment sessions. Both parents and children rated the treatment as highly satisfactory. ARFID symptom severity and impairment as well as family accommodation were significantly reduced from pre- to posttreatment. Increases in food-related flexibility are described.

DISCUSSION

Findings provide preliminary evidence that SPACE-ARFID, a parent-based treatment that focuses on parental responses to the ARFID symptoms is feasible, acceptable, and satisfactory and produces improvement in clinical outcomes.

Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Feasibility, acceptability, and proof-of-concept for children and adolescents

OBJECTIVE

Little is known about the optimal treatment of avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate feasibility, acceptability, and proof-of-concept for cognitive-behavioral therapy for ARFID (CBT-AR) in children and adolescents.

METHOD

Males and females (ages 10-17 years) were offered 20-30 sessions of CBT-AR delivered in a family-based or individual format.

RESULTS

Of 25 eligible individuals, 20 initiated treatment, including 17 completers and 3 dropouts. Using intent-to-treat analyses, clinicians rated 17 patients (85%) as "much improved" or "very much improved." ARFID severity scores (on the Pica, ARFID, and Rumination Disorder Interview) significantly decreased per both patient and parent report. Patients incorporated a mean of 16.7 (SD = 12.1) new foods from pre- to post-treatment. The underweight subgroup showed a significant weight gain of 11.5 (SD = 6.0) pounds, moving from the 10th to the 20th percentile for body mass index. At post-treatment, 70% of patients no longer met criteria for ARFID.

DISCUSSION

This is the first study of an outpatient manualized psychosocial treatment for ARFID in older adolescents. Findings provide evidence of feasibility, acceptability, and proof-of-concept for CBT-AR. Randomized controlled trials are needed.

Childhood Avoidant/Restrictive Food Intake Disorder: Review of Treatments and a Novel Parent-Based Approach

Avoidant/Restrictive food intake disorder (ARFID) is characterized by dietary restrictions that are not based on weight or shape concerns but that result in marked interference in feeding, growth, or psychosocial functioning (American Psychiatric Association, 2013; Eddy et al., 2019). The aim of the current article was to review available reports of treatment for childhood ARFID published since its inclusion in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and to introduce a novel parent-based treatment for child ARFID through a case presentation. Empirical support for psychosocial treatments for child ARFID currently stems from two small-scale pilot randomized control trials, one pilot open trial, case reports, case series, and retrospective chart reviews. Treatment approaches for outpatient care generally apply family-based therapy, child-centered cognitive behavioral therapy, or parent-based behavioral approaches. SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits. SPACE-ARFID aims to promote flexibility and adjustment in food related situations. The treatment helps parents to systematically reduce family accommodation, or changes that they make to their own behavior to help their child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms.

Feeding and eating disorders

Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence-a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.